Provider Demographics
NPI:1396955621
Name:GIBSON, MARY L (MA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4575 LITTLE MOUNTAIN DR
Mailing Address - Street 2:27
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-4917
Mailing Address - Country:US
Mailing Address - Phone:909-567-7975
Mailing Address - Fax:909-567-7975
Practice Address - Street 1:2275 E COOLEY DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-6324
Practice Address - Country:US
Practice Address - Phone:909-370-1777
Practice Address - Fax:909-370-1776
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5709OtherSIMON STAFF NUMBER