Provider Demographics
NPI:1992757280
Name:GIBSON, LAURA E (PHD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4838
Mailing Address - Country:US
Mailing Address - Phone:802-238-2600
Mailing Address - Fax:
Practice Address - Street 1:33 CATHERINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4838
Practice Address - Country:US
Practice Address - Phone:802-238-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2011-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0480000821103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009529Medicaid
VT59513OtherBC BS
GIVN 3094Medicare ID - Type Unspecified