=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285919258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY BLAIR GIBSON LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2011
-----------------------------------------------------
Last Update Date | 10/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 NORTH ANDREWS AVENUE
-----------------------------------------------------
City | FT. LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-463-4217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7380 NW1ST SREET. 103-4
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-583-4903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH6356
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------