MEDICARE: MAVIS B VANBIBBER 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	CSW001526	GA

General Provider Information

NPI Number	:	1770624025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAVIS B VANBIBBER LCSW

Provider Business Mailing Address
First Line	:	940 GA HWY 96
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31088-2587
Country	:	US
Telephone Number	:	478-988-1222
Fax Number	:	478-988-1050

Provider Business Practice Location Address
First Line	:	940 GA HWY 96
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31088-2587
Country	:	US
Telephone Number	:	478-988-1222
Fax Number	:	478-988-1050

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

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	03/06/2008

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