Provider Demographics
NPI:1255526174
Name:GIBSON, GARY GRANT (LPC, NCC, LPCC,)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:GRANT
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LPC, NCC, LPCC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11071 W WEGENER RD
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-8215
Mailing Address - Country:US
Mailing Address - Phone:540-682-3498
Mailing Address - Fax:
Practice Address - Street 1:1601 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-8648
Practice Address - Country:US
Practice Address - Phone:540-682-3498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003993101YM0800X
MN00016101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255526174Medicaid