Provider Demographics
NPI:1336338557
Name:GIBSON, LAJUAN S (LMSW)
Entity type:Individual
Prefix:
First Name:LAJUAN
Middle Name:S
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 320152
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-0003
Mailing Address - Country:US
Mailing Address - Phone:810-406-8727
Mailing Address - Fax:810-768-7985
Practice Address - Street 1:6419 W CIMARRON TRL
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-2022
Practice Address - Country:US
Practice Address - Phone:810-406-8727
Practice Address - Fax:810-768-7985
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010889261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical