Provider Demographics
NPI:1770617490
Name:GIBBS, SEAN (PSYD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:GIBBS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70053-2307
Mailing Address - Country:US
Mailing Address - Phone:504-309-6798
Mailing Address - Fax:504-407-2115
Practice Address - Street 1:3616 S I 10 SERVICE RD W STE 200
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-1874
Practice Address - Country:US
Practice Address - Phone:504-838-5424
Practice Address - Fax:504-838-5714
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAIMF49880225400000X
LA1492103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPO1546OtherDMH STAFF CODE