Provider Demographics
NPI:1740534650
Name:GIBSON, GREGORY W (MA, MFT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 W ROBINHOOD DR
Mailing Address - Street 2:SUITE A8
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5625
Mailing Address - Country:US
Mailing Address - Phone:209-954-7650
Mailing Address - Fax:
Practice Address - Street 1:1151 W ROBINHOOD DR
Practice Address - Street 2:SUITE A8
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5625
Practice Address - Country:US
Practice Address - Phone:209-954-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC52371106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist