Provider Demographics
NPI:1386158228
Name:GIBSON, DIANE FAYE (BA, LSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:FAYE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:BA, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 HUDGINS ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3535
Mailing Address - Country:US
Mailing Address - Phone:304-752-7830
Mailing Address - Fax:304-752-7832
Practice Address - Street 1:313 HUDGINS ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3535
Practice Address - Country:US
Practice Address - Phone:304-752-7830
Practice Address - Fax:304-752-7832
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC362704104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker