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NPI Code Detail

MEDICARE: CARLY R GIBSON

MEDICARE: CARLY R GIBSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program
2106H00000XMarriage & Family TherapistIMF81677CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11023459260OTHERCAUC DAVIS CHILDREN'S HOSPITAL, CAARE CENTER

General Provider Information

NPI Number : 1023459260
Entity Type Code : Individual
Provider Name (Legal Business Name) : CARLY R GIBSON
Provider Business Mailing Address
First Line : 3671 BUSINESS DR
Second Line :
City : SACRAMENTO
State : CA
Zip : 95820-2197
Country : US
Telephone Number : 916-889-6097
Fax Number :
Provider Business Practice Location Address
First Line : 3671 BUSINESS DR
Second Line :
City : SACRAMENTO
State : CA
Zip : 95820-2197
Country : US
Telephone Number : 916-734-8396
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/16/2013
Last Update Date : 01/03/2022

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