Provider Demographics
NPI:1649275793
Name:GIBSON, KEITH F (PHD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:F
Last Name:GIBSON
Suffix:
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 1:2100 ASBURY RD
Mailing Address - Street 2:STE 5
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-3091
Mailing Address - Country:US
Mailing Address - Phone:563-556-1225
Mailing Address - Fax:563-556-0713
Practice Address - Street 1:2100 ASBURY RD
Practice Address - Street 2:STE 5
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-3091
Practice Address - Country:US
Practice Address - Phone:563-556-1225
Practice Address - Fax:563-556-0713
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA342103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI11880Medicare ID - Type Unspecified
IAI11880Medicare UPIN