Provider Demographics
NPI:1194875658
Name:GIBSON, DIANNE
Entity type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:
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 1:2901 BAKERS MILL RD
Mailing Address - Street 2:2901 BAKERS MILL RD
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-8273
Mailing Address - Country:US
Mailing Address - Phone:910-423-8816
Mailing Address - Fax:910-423-8816
Practice Address - Street 1:2901 BAKERS MILL RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-8273
Practice Address - Country:US
Practice Address - Phone:910-423-8816
Practice Address - Fax:910-423-8816
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409525Medicaid