Provider Demographics
NPI:1871827642
Name:GIBBON, HEATHER L (MSW INTERN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:GIBBON
Suffix:
Gender:F
Credentials:MSW INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 SAINT GERMAIN ST
Mailing Address - Street 2:APT. 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-3258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 MEDFORD ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3421
Practice Address - Country:US
Practice Address - Phone:617-629-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program