Healthcare Provider Details

I. General information

NPI: 1780042770
Provider Name (Legal Business Name): MS. KRISTIN JOY GIBB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTIN JOY GORTON M.A.. L.M.H.C.A.

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 11TH AVE
LONGVIEW WA
98632-2555
US

IV. Provider business mailing address

7618 SE RAYMOND ST
PORTLAND OR
97206-4332
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-8600
  • Fax:
Mailing address:
  • Phone: 503-544-4340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60630862
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: