Provider Demographics
NPI:1689164212
Name:GIBSON, GRANT
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:GIBSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4829 E BELTLINE AVE NE STE 310
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9350
Mailing Address - Country:US
Mailing Address - Phone:616-279-6414
Mailing Address - Fax:616-588-6036
Practice Address - Street 1:4829 E BELTLINE AVE NE STE 310
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9350
Practice Address - Country:US
Practice Address - Phone:616-279-6414
Practice Address - Fax:616-588-6036
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician