Provider Demographics
NPI:1447398292
Name:GIBSON, OWEN (MA)
Entity type:Individual
Prefix:MR
First Name:OWEN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20109 NE HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-8781
Mailing Address - Country:US
Mailing Address - Phone:503-205-4342
Mailing Address - Fax:503-230-1371
Practice Address - Street 1:3415 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3371
Practice Address - Country:US
Practice Address - Phone:503-205-4342
Practice Address - Fax:503-230-1371
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health