Basic Information
| Provider Information | |||||||||
| NPI: | 1295270080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.A, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8148 GENESEE AVE APT 88 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921221467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582472405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5480 BALTIMORE DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919422020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197336414 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2017 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 97630 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.