MEDICARE: KATIE ALLYSON GIBBONS LMSW

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	101YM0800X	Mental Health Counselor	101761	NY

General Provider Information

NPI Number	:	1417841867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE ALLYSON GIBBONS LMSW

Provider Business Mailing Address
First Line	:	11 WALNUT RUN
Second Line	:
City	:	FAIRPORT
State	:	NY
Zip	:	14450-3825
Country	:	US
Telephone Number	:	585-794-1055
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 E MAIN ST
Second Line	:
City	:	VICTOR
State	:	NY
Zip	:	14564-1334
Country	:	US
Telephone Number	:	585-905-5468
Fax Number	:

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

Provider Enumeration Date	:	06/09/2025
Last Update Date	:	06/09/2025

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