MEDICARE: SARAH GIBBONS

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	LC50081026	DC
2	1041C0700X	Clinical Social Worker	16422	MD

General Provider Information

NPI Number	:	1770002255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH GIBBONS

Provider Business Mailing Address
First Line	:	6950 COLUMBIA GATEWAY DR
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21046-2706
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4231 BALBOA AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-5504
Country	:	US
Telephone Number	:	410-251-3984
Fax Number	:

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

Provider Enumeration Date	:	09/15/2017
Last Update Date	:	08/29/2019

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