MEDICARE: MS. ALIX MATTY GIBSON LICSW

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	104100000X	Social Worker	0890000970	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912178708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ALIX MATTY GIBSON LICSW

Provider Business Mailing Address
First Line	:	20 HOUGHTON ST
Second Line	:	SUITE 211
City	:	SAINT ALBANS
State	:	VT
Zip	:	05478-2227
Country	:	US
Telephone Number	:	802-524-4953
Fax Number	:	802-527-5404

Provider Business Practice Location Address
First Line	:	20 HOUGHTON ST
Second Line	:	SUITE 211
City	:	SAINT ALBANS
State	:	VT
Zip	:	05478-2227
Country	:	US
Telephone Number	:	802-524-4953
Fax Number	:	802-527-5404

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

Provider Enumeration Date	:	03/19/2008
Last Update Date	:	03/19/2008

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