MEDICARE: KIMBERLY GIBSON

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	101Y00000X	Counselor	06-05AE-PL	AR
2	101YP2500X	Professional Counselor	CI0010	NV

General Provider Information

NPI Number	:	1548325012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY GIBSON

Provider Business Mailing Address
First Line	:	PO BOX 572238
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89157-2238
Country	:	US
Telephone Number	:	702-338-4034
Fax Number	:

Provider Business Practice Location Address
First Line	:	4588 N RANCHO DR
Second Line	:	SUITE 12
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3426
Country	:	US
Telephone Number	:	702-396-3464
Fax Number	:

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

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	10/07/2009

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Directions to “ KIMBERLY GIBSON ” Practice Location

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