Provider Demographics
NPI:1780201814
Name:GIBSON, SARAH (LLMSW)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:STANZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2172 DEAN LAKE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4444
Mailing Address - Country:US
Mailing Address - Phone:616-451-2021
Mailing Address - Fax:
Practice Address - Street 1:2172 DEAN LAKE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-4444
Practice Address - Country:US
Practice Address - Phone:616-451-2021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X
MI68511160341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No156F00000XEye and Vision Services ProvidersTechnician/Technologist