Provider Demographics
NPI:1417841867
Name:GIBBONS, KATIE ALLYSON (LMSW)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ALLYSON
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ALLYSON
Other - Last Name:LINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:11 WALNUT RUN
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3825
Mailing Address - Country:US
Mailing Address - Phone:585-794-1055
Mailing Address - Fax:
Practice Address - Street 1:10 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-1334
Practice Address - Country:US
Practice Address - Phone:585-905-5468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101761101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health