Provider Demographics
NPI:1588997043
Name:GIBSON, HEIDI MARIA (LICSW ICADC)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LICSW ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2892 SUNLIGHT DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WA
Mailing Address - Zip Code:98236-9005
Mailing Address - Country:US
Mailing Address - Phone:360-929-9486
Mailing Address - Fax:
Practice Address - Street 1:3475 N SARATOGA ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98278-4927
Practice Address - Country:US
Practice Address - Phone:360-257-9484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 601177751041C0700X
IDCADC 1142006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)