Provider Demographics
NPI:1295177624
Name:GIBSON, DAYRELL (LLBSW)
Entity type:Individual
Prefix:
First Name:DAYRELL
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 N GROESBECK HWY
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-1562
Mailing Address - Country:US
Mailing Address - Phone:248-599-8999
Mailing Address - Fax:
Practice Address - Street 1:175 N GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-1562
Practice Address - Country:US
Practice Address - Phone:248-599-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL24208581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381917278OtherWORK IDENTIFIER