Provider Demographics
NPI:1629761549
Name:GIBSON, ANTHONY E SR
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:E
Last Name:GIBSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 WILLOW ROCK LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4332
Mailing Address - Country:US
Mailing Address - Phone:817-909-5157
Mailing Address - Fax:
Practice Address - Street 1:777 MAIN ST STE 600
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5368
Practice Address - Country:US
Practice Address - Phone:817-909-5157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 172V00000X, 385HR2055X, 374700000X, 3747P1801X, 385H00000X, 343900000X, 3747P1801X, 385H00000X, 385HR2055X, 106S00000X
TX169230772871261QM0801X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No385H00000XRespite Care FacilityRespite Care
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)