MEDICARE: LACEY 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	224Z00000X	Occupational Therapy Assistant
2	1041C0700X	Clinical Social Worker	116400	CA

General Provider Information

NPI Number	:	1619479581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY GIBSON

Provider Business Mailing Address
First Line	:	251 S OAK PARK BLVD APT 44
Second Line	:
City	:	GROVER BEACH
State	:	CA
Zip	:	93433-4214
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 E BRANCH ST STE G
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-2738
Country	:	US
Telephone Number	:	805-936-0374
Fax Number	:

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

Provider Enumeration Date	:	03/06/2018
Last Update Date	:	03/10/2026

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Directions to “ LACEY GIBSON ” Practice Location

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