Provider Demographics
NPI:1750801981
Name:GIBSON, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
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 1:3600 FORBES AVENUE
Mailing Address - Street 2:FORBES TOWER- PLAZA SUITE 140
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 FORBES AVENUE
Practice Address - Street 2:FORBES TOWER- PLAZA SUITE 140
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213
Practice Address - Country:US
Practice Address - Phone:412-647-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV327072084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry