Healthcare Provider Details

I. General information

NPI: 1841113693
Provider Name (Legal Business Name): SUSAN ANNETTE GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10379 DEMOCRACY LN
FAIRFAX VA
22030-2505
US

IV. Provider business mailing address

10379 DEMOCRACY LN
FAIRFAX VA
22030-2505
US

V. Phone/Fax

Practice location:
  • Phone: 571-331-0434
  • Fax:
Mailing address:
  • Phone: 571-331-0434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0704019339
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: