Basic Information
| Provider Information | |||||||||
| NPI: | 1346792447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LLMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POWELL | ||||||||
| OtherFirstName: | DENISE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3830 LAKE DR SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495464345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084667118 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1101 BALL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495055904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164566571 | ||||||||
| FaxNumber: | 6164585430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2016 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801099689 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.