Individual
MARY L GIBSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MS
Contact information
Practice address
301 E SAINT JOSEPH ST, GREEN BAY, WI 54301-2241
(920) 430-3630
Mailing address
301 E SAINT JOSEPH ST, GREEN BAY, WI 54301-2241
(920) 430-3630
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
1196-125
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1196-125
LICENSE NUMBER
WI
05
—
43561600
—
WI
Enumeration date
05/21/2007
Last updated
07/09/2007
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