Provider Demographics
NPI:1396106431
Name:GIBBONS, SHARIFF
Entity type:Individual
Prefix:
First Name:SHARIFF
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 PARK PLACE
Mailing Address - Street 2:
Mailing Address - City:BROOKYLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217
Mailing Address - Country:US
Mailing Address - Phone:347-359-7894
Mailing Address - Fax:
Practice Address - Street 1:2939 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468
Practice Address - Country:US
Practice Address - Phone:347-359-7894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096201104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker