MEDICARE: FAMATTA 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
1	1041C0700X	Clinical Social Worker	014798
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1194487215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAMATTA GIBSON

Provider Business Mailing Address
First Line	:	51 BEVERLY RD
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06515-1533
Country	:	US
Telephone Number	:	203-350-9278
Fax Number	:

Provider Business Practice Location Address
First Line	:	51 BEVERLY RD
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06515-1533
Country	:	US
Telephone Number	:	203-350-9278
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2021
Last Update Date	:	10/19/2025

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Directions to “ FAMATTA GIBSON ” Practice Location

Language	Start Address	Practice Location

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