Provider Demographics
NPI:1255093498
Name:GIBSON, MARY M (LCSWA, MSM)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LCSWA, MSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4822 ALBEMARLE RD STE 219
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-6656
Mailing Address - Country:US
Mailing Address - Phone:704-405-4262
Mailing Address - Fax:704-405-4262
Practice Address - Street 1:4822 ALBEMARLE ROAD, SUIT 219
Practice Address - Street 2:
Practice Address - City:CHARLOTTE,
Practice Address - State:NC
Practice Address - Zip Code:28205-6668
Practice Address - Country:US
Practice Address - Phone:704-914-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0156721041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical