Basic Information
| Provider Information | |||||||||
| NPI: | 1770842676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBS | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | LORRAINE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7760 MYERS RD | ||||||||
| Address2: | |||||||||
| City: | KIRKVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130829779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156562574 | ||||||||
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| Practice Location | |||||||||
| Address1: | 138 NORTH COURT ST | ||||||||
| Address2: | VETERAN'S MEMORIAL BUILDING, 2ND FLOOR | ||||||||
| City: | WAMPSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153662327 | ||||||||
| FaxNumber: | 3153662599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 05/11/2012 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.