Provider Demographics
NPI:1386863751
Name:GIBBONS, MARY ELIZABETH (LAC, NCCAOM DIPL)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:LAC, NCCAOM DIPL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6207 HARDY DR
Mailing Address - Street 2:
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3115
Mailing Address - Country:US
Mailing Address - Phone:703-893-1537
Mailing Address - Fax:
Practice Address - Street 1:11250 ROGER BACON DR
Practice Address - Street 2:SUITE 23
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5219
Practice Address - Country:US
Practice Address - Phone:703-231-5058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000334171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist