Provider Demographics
NPI:1114768801
Name:GIBSON, MICHAELA KATHLEEN
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:KATHLEEN
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 1:191 NW LEXINGTON DR APT 206
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-6910
Mailing Address - Country:US
Mailing Address - Phone:515-450-7230
Mailing Address - Fax:
Practice Address - Street 1:6200 AURORA AVE STE 305E
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-2863
Practice Address - Country:US
Practice Address - Phone:515-724-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA126476101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health