Provider Demographics
NPI:1861516981
Name:GIBSON, ELIZABETH A (LCPC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-3219
Mailing Address - Country:US
Mailing Address - Phone:208-861-1844
Mailing Address - Fax:
Practice Address - Street 1:300 W MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7707
Practice Address - Country:US
Practice Address - Phone:208-861-1844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-381101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002269500Medicaid
IDX4195OtherBLUE CROSS
ID000010032814OtherREGENCE BLUE SHIELD
IDQ2495OtherBLUE CROSS