Provider Demographics
NPI:1245991702
Name:GIBSON, ALYSSA NICOLE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:NICOLE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 OUTBACK LOOP
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:ID
Mailing Address - Zip Code:83869-8600
Mailing Address - Country:US
Mailing Address - Phone:208-889-9710
Mailing Address - Fax:
Practice Address - Street 1:7905 N MEADOWLARK WAY STE D
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-5041
Practice Address - Country:US
Practice Address - Phone:208-618-2593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician