MEDICARE: MR. PATRICK ROBERT GIBSON LPC, LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	10812	TX

General Provider Information

NPI Number	:	1033288055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PATRICK ROBERT GIBSON LPC, LMFT

Provider Business Mailing Address
First Line	:	1716 WATSON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-2044
Country	:	US
Telephone Number	:	817-451-3380
Fax Number	:	817-451-1331

Provider Business Practice Location Address
First Line	:	1020 S CARRIER PKWY
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-1527
Country	:	US
Telephone Number	:	214-743-1200
Fax Number	:	817-451-1331

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	06/14/2023

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