MEDICARE: GIBSON ALVAREZ INCORPORATED, LLC

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	34006028A	IN

General Provider Information

NPI Number	:	1891095832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GIBSON ALVAREZ INCORPORATED, LLC

Provider Business Mailing Address
First Line	:	5731 BROCKTON DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-5443
Country	:	US
Telephone Number	:	717-271-1072
Fax Number	:

Provider Business Practice Location Address
First Line	:	5731 BROCKTON DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-5443
Country	:	US
Telephone Number	:	717-271-1072
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JULIE MARIE GIBSON ALVAREZ
Credential	:	LCSW
Telephone Number	:	717-271-1072

Provider Enumeration Date	:	10/25/2010
Last Update Date	:	04/21/2011

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