Healthcare Provider Details

I. General information

NPI: 1447179148
Provider Name (Legal Business Name): KYLIE GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BAXTER ST STE 420-421
CHARLOTTE NC
28204-3053
US

IV. Provider business mailing address

1300 BAXTER ST STE 420-421
CHARLOTTE NC
28204-3053
US

V. Phone/Fax

Practice location:
  • Phone: 704-995-0342
  • Fax: 704-943-0707
Mailing address:
  • Phone: 704-995-0342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP024028
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: