MEDICARE: GRANT GIBSON

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	103K00000X	Behavior Analyst
3	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1689164212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRANT GIBSON

Provider Business Mailing Address
First Line	:	4829 E BELTLINE AVE NE STE 310
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9350
Country	:	US
Telephone Number	:	616-279-6414
Fax Number	:	616-588-6036

Provider Business Practice Location Address
First Line	:	4829 E BELTLINE AVE NE STE 310
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9350
Country	:	US
Telephone Number	:	616-279-6414
Fax Number	:	616-588-6036

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

Provider Enumeration Date	:	05/18/2018
Last Update Date	:	10/02/2025

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Directions to “ GRANT GIBSON ” Practice Location

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