Provider Demographics
NPI:1386810851
Name:GIBBONS, STACIE JOYCE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:JOYCE
Last Name:GIBBONS
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 1:1953 S GREAT BASIN DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-8258
Mailing Address - Country:US
Mailing Address - Phone:435-632-5135
Mailing Address - Fax:
Practice Address - Street 1:254 S 1470 E STE 201
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2762
Practice Address - Country:US
Practice Address - Phone:435-932-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health