1982205217 NPI number — MRS. STEFANIE MARIE GIBBONS ASW

Table of content: MRS. STEFANIE MARIE GIBBONS ASW (NPI 1982205217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982205217 NPI number — MRS. STEFANIE MARIE GIBBONS ASW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBBONS
Provider First Name:
STEFANIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ASW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALLACE
Provider Other First Name:
STEFANIE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982205217
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45340 WINDMILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COARSEGOLD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93614-9345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-468-1094
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45340 WINDMILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COARSEGOLD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93614-9345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-468-1094
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2020

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: 390200000X , with the licence number:  1982205217 , 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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