Provider Demographics
NPI:1336611532
Name:GIBSON, TAMARA LYNN
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LYNN
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 1:6157 145TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-8974
Mailing Address - Country:US
Mailing Address - Phone:616-834-1246
Mailing Address - Fax:
Practice Address - Street 1:750 E 40TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-5342
Practice Address - Country:US
Practice Address - Phone:616-368-2294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801097197104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker