Provider Demographics
NPI:1063986891
Name:GIBSON, STEFAN
Entity type:Individual
Prefix:
First Name:STEFAN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 E HIGHLAND AVE STE B200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4741
Mailing Address - Country:US
Mailing Address - Phone:602-855-0445
Mailing Address - Fax:
Practice Address - Street 1:3033 N CENTRAL AVE STE 700
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2806
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional