Basic Information
| Provider Information | |||||||||
| NPI: | 1659979607 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97 MANHATTAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ISLIP TERRACE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316879469 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 90 ADAMS AVE | ||||||||
| Address2: | |||||||||
| City: | HAUPPAUGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319523333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2020 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 110146 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.