MEDICARE: SOLENA MARIE GIBSON LISW-S

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	I.1801077-SUPV	OH

General Provider Information

NPI Number	:	1609473404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOLENA MARIE GIBSON LISW-S

Provider Business Mailing Address
First Line	:	3271 GROVEPARK DR
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-4805
Country	:	US
Telephone Number	:	614-753-7421
Fax Number	:

Provider Business Practice Location Address
First Line	:	27070 CEDAR RD
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-8131
Country	:	US
Telephone Number	:	216-831-2881
Fax Number	:

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

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	10/05/2020

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