Provider Demographics
NPI:1265693584
Name:GIBSON, LINDA ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:ELIZABETH
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 1:180 COASTAL LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6761
Mailing Address - Country:US
Mailing Address - Phone:910-455-6724
Mailing Address - Fax:910-346-5489
Practice Address - Street 1:180 COASTAL LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6761
Practice Address - Country:US
Practice Address - Phone:910-455-6724
Practice Address - Fax:910-346-5489
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-067-026320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408956Medicaid