Healthcare Provider Details

I. General information

NPI: 1275633760
Provider Name (Legal Business Name): ELIZABETH GIBSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 STERLING ST SUITE 35
WEST BOYLSTON MA
01583-1200
US

IV. Provider business mailing address

45 STERLING ST SUITE 35
WEST BOYLSTON MA
01583-1200
US

V. Phone/Fax

Practice location:
  • Phone: 508-754-6444
  • Fax: 978-464-5838
Mailing address:
  • Phone: 508-754-6444
  • Fax: 978-464-5838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5096
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: