Healthcare Provider Details

I. General information

NPI: 1396062535
Provider Name (Legal Business Name): KERIMA A. GIBBONS LICSW, BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 24TH ST
FORT LEE VA
23801-1716
US

IV. Provider business mailing address

17010 LONGLEAF DR
BOWIE MD
20716-3634
US

V. Phone/Fax

Practice location:
  • Phone: 804-734-9942
  • Fax: 804-874-1008
Mailing address:
  • Phone: 301-809-3675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC301640
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: