Provider Demographics
NPI:1720802457
Name:GIBSON, ALEXIS MARIE
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MARIE
Last Name:GIBSON
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 1:1236 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-3842
Mailing Address - Country:US
Mailing Address - Phone:704-402-2610
Mailing Address - Fax:
Practice Address - Street 1:171 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9500
Practice Address - Country:US
Practice Address - Phone:704-660-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0177101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical