Provider Demographics
NPI:1386778918
Name:GIBSON, CONNIE J (MSSW LICSW)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MSSW LICSW
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:HECKENLAIBLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:540 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1600
Mailing Address - Country:US
Mailing Address - Phone:952-442-4437
Mailing Address - Fax:952-442-3084
Practice Address - Street 1:540 E 1ST ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1600
Practice Address - Country:US
Practice Address - Phone:952-442-4437
Practice Address - Fax:952-442-3084
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW4945104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker