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NPI Code Detail

MEDICARE: MELISSA RAEN'E GIBBONS LLMSW

MEDICARE: MELISSA RAEN'E GIBBONS LLMSW
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
1104100000XSocial Worker6801102550MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
16801102550OTHERMIDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS - MASTER LTD SOCIAL WORKER

General Provider Information

NPI Number : 1205308632
Entity Type Code : Individual
Provider Name (Legal Business Name) : MELISSA RAEN'E GIBBONS LLMSW
Provider Business Mailing Address
First Line : 14100 NEWBURGH RD
Second Line :
City : LIVONIA
State : MI
Zip : 48154-5010
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 14100 NEWBURGH RD
Second Line :
City : LIVONIA
State : MI
Zip : 48154-5010
Country : US
Telephone Number : 734-464-7810
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/25/2018
Last Update Date : 12/25/2018

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