MEDICARE: DEBRA JEAN GIBSON LSUDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	6926577-6006	UT

General Provider Information

NPI Number	:	1922592997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA JEAN GIBSON LSUDC

Provider Business Mailing Address
First Line	:	5689 S REDWOOD RD UNIT 30
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84123-5499
Country	:	US
Telephone Number	:	801-268-1715
Fax Number	:

Provider Business Practice Location Address
First Line	:	5689 S REDWOOD RD UNIT 30
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84123-5499
Country	:	US
Telephone Number	:	801-268-1715
Fax Number	:

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

Provider Enumeration Date	:	06/21/2018
Last Update Date	:	06/21/2018

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