Provider Demographics
NPI:1205194388
Name:GIBBONS, SUSAN B R (PHD, LCSW-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B R
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:PHD, LCSW-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ROSS
Other - Last Name:GIBBONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:488 LYMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-3548
Mailing Address - Country:US
Mailing Address - Phone:410-544-8507
Mailing Address - Fax:410-757-3916
Practice Address - Street 1:1507 RITCHIE HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-2743
Practice Address - Country:US
Practice Address - Phone:410-544-8507
Practice Address - Fax:410-757-3916
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD041531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ487Medicare PIN