Basic Information
| Provider Information | |||||||||
| NPI: | 1043543465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | PROF. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. ED. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5415 BRIAN HAVEN DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770915503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136881811 | ||||||||
| FaxNumber: | 7136881911 | ||||||||
| Practice Location | |||||||||
| Address1: | 4625 NORTH FWY | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770222914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136970776 | ||||||||
| FaxNumber: | 7136972309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2009 | ||||||||
| LastUpdateDate: | 02/22/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 7635 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1634099 01 | 05 | TX | MEDICAID |