Provider Demographics
NPI:1033514112
Name:MCGIBBON, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:MCGIBBON
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 1:54 BUELL ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-4311
Mailing Address - Country:US
Mailing Address - Phone:870-355-1301
Mailing Address - Fax:
Practice Address - Street 1:54 BUELL ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-4311
Practice Address - Country:US
Practice Address - Phone:870-355-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0087341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical