Provider Demographics
NPI:1376298802
Name:GIBBONS, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:GIBBONS
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 1:2481 LEWIS LN
Mailing Address - Street 2:
Mailing Address - City:FINKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21048-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1110 BENFIELD BLVD STE B
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-2644
Practice Address - Country:US
Practice Address - Phone:410-863-7213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LGP12374101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health