MEDICARE: MS. ANDREA GIBBS WILSON LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	2001026801	MO

General Provider Information

NPI Number	:	1265596530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANDREA GIBBS WILSON LPC

Provider Business Mailing Address
First Line	:	13300 SE US HIGHWAY 169
Second Line	:
City	:	GOWER
State	:	MO
Zip	:	64454-8364
Country	:	US
Telephone Number	:	816-769-6129
Fax Number	:	816-424-6782

Provider Business Practice Location Address
First Line	:	5950 N OAK TRFY STE 104
Second Line	:
City	:	GLADSTONE
State	:	MO
Zip	:	64118-5164
Country	:	US
Telephone Number	:	816-769-6129
Fax Number	:	816-424-6782

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	07/08/2007

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