Provider Demographics
NPI:1962439059
Name:GIBSON, WILLIAM (PHD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 FORT HILL AVE
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1159
Mailing Address - Country:US
Mailing Address - Phone:585-393-7496
Mailing Address - Fax:585-393-7429
Practice Address - Street 1:400 FORT HILL AVE
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1159
Practice Address - Country:US
Practice Address - Phone:585-393-7496
Practice Address - Fax:585-393-7429
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017177103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA423635OtherPA BLUE SHILED
PA651123-01OtherBC/BS OF MD CARE FIRST
PA835851000OtherMAGELLAN
PA50058633OtherCAPTIAL BLUE CROSS
PA423635OtherPA BLUE SHILED