Healthcare Provider Details

I. General information

NPI: 1346134228
Provider Name (Legal Business Name): MELISSA GIBB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30701 BARRINGTON ST
MADISON HEIGHTS MI
48071-5106
US

IV. Provider business mailing address

510 FOREST AVE
ROYAL OAK MI
48067-1958
US

V. Phone/Fax

Practice location:
  • Phone: 248-965-3916
  • Fax:
Mailing address:
  • Phone: 313-909-2350
  • Fax: 313-909-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401002830
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: