Provider Demographics
NPI:1184003782
Name:GIBSON, MARY (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 543
Mailing Address - Street 2:
Mailing Address - City:KINDERHOOK
Mailing Address - State:NY
Mailing Address - Zip Code:12106-0543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 HUDSON STREET
Practice Address - Street 2:
Practice Address - City:KINDERHOOK
Practice Address - State:NY
Practice Address - Zip Code:12106-0543
Practice Address - Country:US
Practice Address - Phone:518-821-7807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPO45362-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical