Provider Demographics
NPI:1144300872
Name:GIBSON, MICHAEL JAY (EDD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
Last Name:GIBSON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 1ST ST APT 8
Mailing Address - Street 2:
Mailing Address - City:MENOMINEE
Mailing Address - State:MI
Mailing Address - Zip Code:49858-2861
Mailing Address - Country:US
Mailing Address - Phone:906-864-2454
Mailing Address - Fax:
Practice Address - Street 1:2012 10TH ST
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-2194
Practice Address - Country:US
Practice Address - Phone:906-863-5646
Practice Address - Fax:906-863-1078
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007904101YP2500X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional