Provider Demographics
NPI:1356972517
Name:GIBSON, MISHA KAY (LISW-CP)
Entity type:Individual
Prefix:
First Name:MISHA
Middle Name:KAY
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 WILEY DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-6488
Mailing Address - Country:US
Mailing Address - Phone:864-414-1335
Mailing Address - Fax:
Practice Address - Street 1:212 WHITSETT ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3141
Practice Address - Country:US
Practice Address - Phone:864-414-1335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC112951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical