Healthcare Provider Details

I. General information

NPI: 1942781646
Provider Name (Legal Business Name): LESLIE GIBBONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9627 PHILADELPHIA RD STE 160
ROSEDALE MD
21237-4157
US

IV. Provider business mailing address

9627 PHILADELPHIA RD STE 160
ROSEDALE MD
21237-4157
US

V. Phone/Fax

Practice location:
  • Phone: 410-780-5203
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number28776
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: