Provider Demographics
NPI:1336167691
Name:GIBBS, ROSE MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24410
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0451
Mailing Address - Country:US
Mailing Address - Phone:541-902-6140
Mailing Address - Fax:541-902-7533
Practice Address - Street 1:1525 12TH ST STE 22
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-8487
Practice Address - Country:US
Practice Address - Phone:541-902-0408
Practice Address - Fax:541-902-7533
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL33891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORL3389OtherSTATE LICENSE
OR027905Medicaid
ORR118402Medicare PIN