Provider Demographics
NPI:1982205217
Name:GIBBONS, STEFANIE MARIE (ASW)
Entity Type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:MARIE
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:MARIE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45340 WINDMILL RD
Mailing Address - Street 2:
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614-9345
Mailing Address - Country:US
Mailing Address - Phone:281-468-1094
Mailing Address - Fax:
Practice Address - Street 1:45340 WINDMILL RD
Practice Address - Street 2:
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614-9345
Practice Address - Country:US
Practice Address - Phone:281-468-1094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1982205217390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program