Provider Demographics
NPI:1780983338
Name:GIBSON, GAYLA R (MA, LPC)
Entity type:Individual
Prefix:
First Name:GAYLA
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5517 ALBIA TERR
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-1222
Mailing Address - Country:US
Mailing Address - Phone:314-385-9550
Mailing Address - Fax:
Practice Address - Street 1:11042 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-6312
Practice Address - Country:US
Practice Address - Phone:314-385-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.014685101YM0800X
133NN1002X, 174H00000X
MO2009035067101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No174H00000XOther Service ProvidersHealth Educator