1417067463 NPI number — MS. MAATISAK AMENHETEP GIPSON L.C.S.W.

Table of content: MS. MAATISAK AMENHETEP GIPSON L.C.S.W. (NPI 1417067463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417067463 NPI number — MS. MAATISAK AMENHETEP GIPSON L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIPSON
Provider First Name:
MAATISAK
Provider Middle Name:
AMENHETEP
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AMENHETEP
Provider Other First Name:
MAATISAK
Provider Other Middle Name:
SAUAT NERA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.C.S.W.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417067463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 GARAVENTA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-564-6715
Provider Business Mailing Address Fax Number:
916-457-2667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6900 2ND STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-564-6715
Provider Business Practice Location Address Fax Number:
916-457-2667
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCS19290 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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