Provider Demographics
NPI:1417067463
Name:GIPSON, MAATISAK AMENHETEP (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MAATISAK
Middle Name:AMENHETEP
Last Name:GIPSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MAATISAK
Other - Middle Name:SAUAT NERA
Other - Last Name:AMENHETEP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1200 GARAVENTA WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833
Mailing Address - Country:US
Mailing Address - Phone:951-564-6715
Mailing Address - Fax:916-457-2667
Practice Address - Street 1:6900 2ND STREET
Practice Address - Street 2:
Practice Address - City:RIO LINDA
Practice Address - State:CA
Practice Address - Zip Code:95673
Practice Address - Country:US
Practice Address - Phone:951-564-6715
Practice Address - Fax:916-457-2667
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS192901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA381041Medicare PIN