Basic Information
| Provider Information | |||||||||
| NPI: | 1205825437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | PUCKETT | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.S., NCC, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2485 HINTON RD | ||||||||
| Address2: | |||||||||
| City: | DACULA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300192155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783772285 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 223 SCENIC HWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300455603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709951846 | ||||||||
| FaxNumber: | 7709956614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 07/23/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC003992 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.