Provider Demographics
NPI:1336912823
Name:GIBSON, WILLIE
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 W MEADOWVIEW RD STE 208
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-3706
Mailing Address - Country:US
Mailing Address - Phone:336-274-1269
Mailing Address - Fax:336-272-2387
Practice Address - Street 1:6113 BLUE LANTERN RD
Practice Address - Street 2:
Practice Address - City:GIBSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27249-8737
Practice Address - Country:US
Practice Address - Phone:336-274-1269
Practice Address - Fax:336-272-2387
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach