Provider Demographics
NPI:1679766059
Name:GIBSON, KIRA DANIELLE (MFT, RD)
Entity type:Individual
Prefix:
First Name:KIRA
Middle Name:DANIELLE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MFT, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3585 MAPLE ST STE 254
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-9108
Mailing Address - Country:US
Mailing Address - Phone:805-223-1021
Mailing Address - Fax:
Practice Address - Street 1:3585 MAPLE ST STE 254
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-9108
Practice Address - Country:US
Practice Address - Phone:805-223-1021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
931856133V00000X
CA139275106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02021ZMedicare PIN
CAQ67681Medicare UPIN