Provider Demographics
NPI:1588702203
Name:GIBSON, PAULA W (PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:PAULA
Middle Name:W
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8340 W FOND DU LAC
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4300
Mailing Address - Country:US
Mailing Address - Phone:414-462-8979
Mailing Address - Fax:414-462-8985
Practice Address - Street 1:3970 N OAKLAND AVE
Practice Address - Street 2:SUITE 502
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-2265
Practice Address - Country:US
Practice Address - Phone:414-962-9909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2738-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40993600Medicaid
WIW12670OtherMEDICARE PTAN