Healthcare Provider Details

I. General information

NPI: 1952680597
Provider Name (Legal Business Name): BRANDY DAISY GEBO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2011
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 CORPORATE DR
BANGOR ME
04401-4314
US

IV. Provider business mailing address

42 CEDAR ST
BANGOR ME
04401-6433
US

V. Phone/Fax

Practice location:
  • Phone: 207-992-2636
  • Fax: 207-947-0435
Mailing address:
  • Phone: 207-947-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC13212
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMC13212
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC14564
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: