Provider Demographics
NPI:1326592940
Name:JEANNIE GIBERSON, LCSW LLC
Entity Type:Organization
Organization Name:JEANNIE GIBERSON, LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GIBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-772-0779
Mailing Address - Street 1:200 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2831
Mailing Address - Country:US
Mailing Address - Phone:207-772-0779
Mailing Address - Fax:
Practice Address - Street 1:200 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2831
Practice Address - Country:US
Practice Address - Phone:207-772-0779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC30541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty