Provider Demographics
NPI:1134426109
Name:GIBBS, SUSAN (LCSW, LADC)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:GIBBS
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:MS
Other - First Name:SUSIE
Other - Middle Name:
Other - Last Name:GIBBS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, LADC
Mailing Address - Street 1:125 WHITING ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-3184
Mailing Address - Country:US
Mailing Address - Phone:860-229-4830
Mailing Address - Fax:860-826-8701
Practice Address - Street 1:92 VINE ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1433
Practice Address - Country:US
Practice Address - Phone:860-229-4830
Practice Address - Fax:860-826-8701
Is Sole Proprietor?:No
Enumeration Date:2011-02-27
Last Update Date:2011-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000121101YA0400X
CT0052551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)