Provider Demographics
NPI:1114716446
Name:GIBSON, MARY
Entity type:Individual
Prefix:
First Name:MARY
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 1:1900 ALDONS WAY
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-9195
Mailing Address - Country:US
Mailing Address - Phone:606-260-3784
Mailing Address - Fax:
Practice Address - Street 1:1900 ALDONS WAY
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-9195
Practice Address - Country:US
Practice Address - Phone:606-260-3784
Practice Address - Fax:606-260-3784
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty