Provider Demographics
NPI:1811481005
Name:GIBBONS-CARR, MICHELE V
Entity type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:V
Last Name:GIBBONS-CARR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:GIBBONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 SKYLINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482
Mailing Address - Country:US
Mailing Address - Phone:781-235-7197
Mailing Address - Fax:781-489-5740
Practice Address - Street 1:4 SKYLINE DRIVE
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482
Practice Address - Country:US
Practice Address - Phone:781-235-7197
Practice Address - Fax:781-489-5740
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3217103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical