Provider Demographics
NPI:1790888998
Name:GIBSON, AMANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:GIBSON-CHI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ASSOCIATE SOCIAL WOR
Mailing Address - Street 1:2617 K ST STE 125
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5133
Mailing Address - Country:US
Mailing Address - Phone:916-425-3311
Mailing Address - Fax:
Practice Address - Street 1:2617 K ST STE 125
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5133
Practice Address - Country:US
Practice Address - Phone:916-425-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA201971041C0700X
CALCS257901041C0700X
CA25790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1790888998Medicaid