Provider Demographics
NPI:1871967927
Name:GIBSON, SALLY (LPC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:1815 PLEASANT GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1101 MORGAN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-3949
Practice Address - Country:US
Practice Address - Phone:870-335-9483
Practice Address - Fax:870-335-9487
Is Sole Proprietor?:No
Enumeration Date:2015-11-30
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ARP2109006101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR228694795Medicaid