Provider Demographics
NPI:1447941893
Name:GIBSON, VERONICA
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 GOLDEN SKY WAY UNIT 165
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-8847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3252 HOLIDAY CT STE 209
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1808
Practice Address - Country:US
Practice Address - Phone:858-230-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141760101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health