Provider Demographics
NPI:1215549878
Name:GIBBS, MONIQUE LA'SHAE
Entity Type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:LA'SHAE
Last Name:GIBBS
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 1:3717 BOSTON ST # 148
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-5752
Mailing Address - Country:US
Mailing Address - Phone:443-800-4985
Mailing Address - Fax:
Practice Address - Street 1:10015 OLD COLUMBIA ROAD
Practice Address - Street 2:SUITE B215
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046
Practice Address - Country:US
Practice Address - Phone:443-800-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician