Provider Demographics
NPI:1063777555
Name:GIBSON, ELIZABETH VIRGINIA (MA, MFTI)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:VIRGINIA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MA, MFTI
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:VIRGINIA
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, MFTI
Mailing Address - Street 1:111 MYRTLE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-2535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 MYRTLE ST STE 102
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2535
Practice Address - Country:US
Practice Address - Phone:510-463-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70807106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist