Provider Demographics
NPI:1194075994
Name:GIBSON, DANIEL GLEN (PSYD, MA, MSW)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:GLEN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PSYD, MA, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 E FRANKLIN RD STE 404
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8917
Mailing Address - Country:US
Mailing Address - Phone:208-258-7917
Mailing Address - Fax:208-417-3088
Practice Address - Street 1:850 E FRANKLIN RD STE 404
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-258-7917
Practice Address - Fax:208-417-3088
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-203026103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical