Basic Information
| Provider Information | |||||||||
| NPI: | 1588817415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | TRAVIS | ||||||||
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| Credential: | MA. LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 299 | ||||||||
| Address2: | 252 COURTHOUSE DRIVE | ||||||||
| City: | WINFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252139370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3045860671 | ||||||||
| Practice Location | |||||||||
| Address1: | 3375 US RT 60 E | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257052837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3045860671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2008 | ||||||||
| LastUpdateDate: | 09/25/2015 | ||||||||
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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 | 101YP2500X | 1914 | WV | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0005355002 | 05 | WV | MEDICAID |