=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962835090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA S GIBSON LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2013
-----------------------------------------------------
Last Update Date | 08/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7739 E 88TH ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46256-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-578-0410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11867 WAPITI WAY
-----------------------------------------------------
City | NOBLESVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46060-7933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 99058324A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------