MEDICARE: MRS. HALEY GIBSON LMFT

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	106H00000X	Marriage & Family Therapist	162595	CA

General Provider Information

NPI Number	:	1407604259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HALEY GIBSON LMFT

Provider Business Mailing Address
First Line	:	615 HEALDSBURG AVE UNIT 221
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-5168
Country	:	US
Telephone Number	:	925-282-0402
Fax Number	:

Provider Business Practice Location Address
First Line	:	3434 MENDOCINO AVE # A
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-2274
Country	:	US
Telephone Number	:	707-284-1978
Fax Number	:	707-708-2188

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

Provider Enumeration Date	:	05/07/2024
Last Update Date	:	04/13/2026

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