=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003932732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. GEORGIA D. GIBSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 HICKORY HILL TRL
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29045-9394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-331-9017
-----------------------------------------------------
Fax | 803-788-7421
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 N MAGNOLIA ST
-----------------------------------------------------
City | SUMTER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29150-4943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-775-9364
-----------------------------------------------------
Fax | 803-773-6615
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 9106
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------