Provider Demographics
NPI:1982744454
Name:GIBSON, STEPHANIE L (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1101 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-2235
Mailing Address - Country:US
Mailing Address - Phone:859-233-4511
Mailing Address - Fax:859-281-3867
Practice Address - Street 1:1101 VETERANS DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-2235
Practice Address - Country:US
Practice Address - Phone:859-233-4511
Practice Address - Fax:859-281-3867
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY3311Medicare ID - Type UnspecifiedMEDICARE