Provider Demographics
NPI:1205925807
Name:GIBSON, WILLIAM JAMES (LMSW LICENSE 5314214)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JAMES
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LMSW LICENSE 5314214
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 NORTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045
Mailing Address - Country:US
Mailing Address - Phone:607-753-0234
Mailing Address - Fax:607-753-0286
Practice Address - Street 1:10 NORTH MAIN ST
Practice Address - Street 2:FAMILY COUNSELING SERVICES
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045
Practice Address - Country:US
Practice Address - Phone:607-753-0234
Practice Address - Fax:607-753-0286
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5314214103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01079267Medicaid