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General NPI Number Information
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NPI Number | 1619479581
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Entity Type | Individual
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Provider Name | LACEY GIBSON
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Gender | Female
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Dates
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Enumeration Date | 03/06/2018
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 793 HIGUERA ST STE 5
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-3571
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Country | US
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Telephone | 805-936-0374
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Fax |
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Provider Business Mailing Address
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Address Line | 251 S OAK PARK BLVD APT 44
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City | GROVER BEACH
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State | CA
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Zip | 93433-4214
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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