Healthcare Provider Details

I. General information

NPI: 1730487901
Provider Name (Legal Business Name): GIBAULT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 S US HIGHWAY 41
TERRE HAUTE IN
47802-4749
US

IV. Provider business mailing address

6401 S US HIGHWAY 41
TERRE HAUTE IN
47802-4749
US

V. Phone/Fax

Practice location:
  • Phone: 812-298-3002
  • Fax: 812-298-3044
Mailing address:
  • Phone: 812-298-3002
  • Fax: 812-298-3044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number73856
License Number StateIN

VIII. Authorized Official

Name: MRS. MICHELE MADLEY
Title or Position: PREIDENT/CEO
Credential: MS LMHC
Phone: 812-298-3002