Provider Demographics
NPI:1104500909
Name:GIBSON BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:GIBSON BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBATU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-599-8267
Mailing Address - Street 1:4425 W OLIVE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-3853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4425 W OLIVE AVE STE 203
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-3853
Practice Address - Country:US
Practice Address - Phone:312-599-8267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)