Provider Demographics
NPI:1386127017
Name:GIBSON, ROSS L (LLP)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14175 TRALEE DR
Mailing Address - Street 2:
Mailing Address - City:CEMENT CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49233-9661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:548 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2921
Practice Address - Country:US
Practice Address - Phone:734-707-1052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003874103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical