Provider Demographics
NPI:1316542855
Name:GIBSON, MALORIE NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:MALORIE
Middle Name:NICOLE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24608 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-2132
Mailing Address - Country:US
Mailing Address - Phone:240-604-7515
Mailing Address - Fax:
Practice Address - Street 1:120 SISTER PIERRE DR STE 403
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7536
Practice Address - Country:US
Practice Address - Phone:410-823-6408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23013104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty