MEDICARE: ALICA K GIBSON MHC, MA

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

General Provider Information

NPI Number	:	1861272049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICA K GIBSON MHC, MA

Provider Business Mailing Address
First Line	:	1114 PATHFINDER CV
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1114 PATHFINDER CV
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9142
Country	:	US
Telephone Number	:	517-677-6336
Fax Number	:

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

Provider Enumeration Date	:	10/04/2023
Last Update Date	:	10/04/2023

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