MEDICARE: MARY LYNNE WILKINS GIBERSON

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	2355S0801X	Speech-Language Assistant	SLPA14766	AZ

General Provider Information

NPI Number	:	1417733890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LYNNE WILKINS GIBERSON

Provider Business Mailing Address
First Line	:	1535 E WINDJAMMER WAY
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-2150
Country	:	US
Telephone Number	:	928-606-6071
Fax Number	:

Provider Business Practice Location Address
First Line	:	1535 E WINDJAMMER WAY
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-2150
Country	:	US
Telephone Number	:	928-606-6071
Fax Number	:

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

Provider Enumeration Date	:	09/01/2023
Last Update Date	:	09/01/2023

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