=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629536396
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA ELIZABETH GIBSON CRC, T-LMCH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2019
-----------------------------------------------------
Last Update Date | 03/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4910 URBANDALE AVE STE 304
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50310-2661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-669-8111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4910 URBANDALE AVE STE 304
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50310-2661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-669-8111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 084646
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------