Provider Demographics
NPI:1093550816
Name:GIBSON, MACKENZIE NOEL
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:NOEL
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PROVIDENCE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2273
Mailing Address - Country:US
Mailing Address - Phone:919-276-0154
Mailing Address - Fax:
Practice Address - Street 1:120 PROVIDENCE RD STE 101
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2273
Practice Address - Country:US
Practice Address - Phone:919-276-0154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPO208541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical