MEDICARE: TAHRIA MARIE GIPSON LCSW

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	9851	FL

General Provider Information

NPI Number	:	1407027972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAHRIA MARIE GIPSON LCSW

Provider Business Mailing Address
First Line	:	9503 PLUM LAKE LN W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-1573
Country	:	US
Telephone Number	:	240-421-9057
Fax Number	:

Provider Business Practice Location Address
First Line	:	9503 PLUM LAKE LN W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-1573
Country	:	US
Telephone Number	:	240-421-9057
Fax Number	:

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

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	08/25/2023

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