Provider Demographics
NPI:1740860568
Name:GIBBONS, MARY LYNNE (LICSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LYNNE
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SUN TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8643
Mailing Address - Country:US
Mailing Address - Phone:256-288-3333
Mailing Address - Fax:
Practice Address - Street 1:5 SUGAR CREEK RD
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-9612
Practice Address - Country:US
Practice Address - Phone:573-223-7649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4625C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical