MEDICARE: TESHANA DENISE GIPSON LCSW, CSOTP, EDD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904004917	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0904004917	OTHER	VA	LCSW

General Provider Information

NPI Number	:	1093898470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TESHANA DENISE GIPSON LCSW, CSOTP, EDD

Provider Business Mailing Address
First Line	:	PO BOX 15808
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-5808
Country	:	US
Telephone Number	:	804-308-1652
Fax Number	:	804-308-1653

Provider Business Practice Location Address
First Line	:	4500 RICHMOND HENRICO TPKE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23222-1346
Country	:	US
Telephone Number	:	804-308-1652
Fax Number	:	804-308-1653

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	01/09/2024

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