Basic Information
| Provider Information | |||||||||
| NPI: | 1386863330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2336 GODDARD PARKWAY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346362 | ||||||||
| Practice Location | |||||||||
| Address1: | 29520 CANVASBACK DR | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216017124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108225007 | ||||||||
| FaxNumber: | 4108225569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 02/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | MD | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 609500303 | 05 | MD | MEDICAID | 609550001 | 05 | MD | MEDICAID | 609550004 | 05 | MD | MEDICAID | LM49EA | 01 | MD | CAREFIRST BCBS GROUP | OTHER | R968 | 01 | CAREFIRST FEDERAL GROUP | OTHER | 517251 | 01 | UHC MAMSI GROUP | OTHER | 609550002 | 05 | MD | MEDICAID | 609500300 | 05 | MD | MEDICAID | 259147000 | 01 | MD | MAGELLAN GROUP | OTHER | 609500301 | 05 | MD | MEDICAID |