Provider Demographics
NPI:1841752847
Name:GIBSON, LORICA (LMSW)
Entity Type:Individual
Prefix:
First Name:LORICA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 WEED RD
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-7460
Mailing Address - Country:US
Mailing Address - Phone:845-820-0997
Mailing Address - Fax:
Practice Address - Street 1:19 DEWITT ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-3913
Practice Address - Country:US
Practice Address - Phone:845-820-0997
Practice Address - Fax:845-524-4740
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102158-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker