Provider Demographics
NPI:1457548067
Name:GIBSON, KENNETH RICHARD III (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RICHARD
Last Name:GIBSON
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18471 HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8513
Mailing Address - Country:US
Mailing Address - Phone:248-735-6713
Mailing Address - Fax:248-349-6893
Practice Address - Street 1:18471 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-8513
Practice Address - Country:US
Practice Address - Phone:248-735-6713
Practice Address - Fax:248-349-6893
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002367103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist