Provider Demographics
NPI:1386247112
Name:GIBSON, NELLY (MSW)
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5816 FAIRWOOD CIR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4605
Mailing Address - Country:US
Mailing Address - Phone:646-251-8354
Mailing Address - Fax:
Practice Address - Street 1:5816 FAIRWOOD CIR NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4605
Practice Address - Country:US
Practice Address - Phone:646-251-8354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty