Healthcare Provider Details

I. General information

NPI: 1376665034
Provider Name (Legal Business Name): ANDREA LYNN GIBBS MA, LPC, NCC, BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HERITAGE DR # 520
SOUTHGATE MI
48195-3094
US

IV. Provider business mailing address

26300 OUTER DR
LINCOLN PARK MI
48146-2019
US

V. Phone/Fax

Practice location:
  • Phone: 734-560-0173
  • Fax:
Mailing address:
  • Phone: 313-388-4603
  • Fax: 313-388-0472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401008014
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401008014
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: