Provider Demographics
NPI:1649499591
Name:GIBSON, MARY ANNE (LMSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1759 230TH ST
Mailing Address - Street 2:
Mailing Address - City:COIN
Mailing Address - State:IA
Mailing Address - Zip Code:51636-4001
Mailing Address - Country:US
Mailing Address - Phone:712-264-4340
Mailing Address - Fax:
Practice Address - Street 1:1800 N 16TH ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-1165
Practice Address - Country:US
Practice Address - Phone:712-542-2388
Practice Address - Fax:712-542-2984
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01722104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker