Provider Demographics
NPI:1902326531
Name:GIBSON, MOLLY KATHERINE (LAC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:KATHERINE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 EAST 12TH STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-8721
Mailing Address - Country:US
Mailing Address - Phone:970-403-5202
Mailing Address - Fax:
Practice Address - Street 1:180 E 12TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5046
Practice Address - Country:US
Practice Address - Phone:970-403-5202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-24
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002123171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist