1871967927 NPI number — SALLY GIBSON LPC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871967927 NPI number — SALLY GIBSON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
SALLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
SALLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LAC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1871967927
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 PLEASANT GROVE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72405-7870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-933-6886
Provider Business Mailing Address Fax Number:
870-933-9395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 MORGAN ST
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
PARAGOULD
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72450-3949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-335-9483
Provider Business Practice Location Address Fax Number:
870-335-9487
Provider Enumeration Date:
11/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: P2109006 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 228694795 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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