Provider Demographics
NPI:1770624025
Name:VANBIBBER, MAVIS B (LCSW)
Entity type:Individual
Prefix:
First Name:MAVIS
Middle Name:B
Last Name:VANBIBBER
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 1:940 GA HWY 96
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2587
Mailing Address - Country:US
Mailing Address - Phone:478-988-1222
Mailing Address - Fax:478-988-1050
Practice Address - Street 1:940 GA HWY 96
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-2587
Practice Address - Country:US
Practice Address - Phone:478-988-1222
Practice Address - Fax:478-988-1050
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0015261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBFMWMedicare ID - Type UnspecifiedMEDICARE NUMBER