Provider Demographics
NPI:1427691807
Name:GIBSON, TRACY (LGSW, LMSW, LCSWA)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LGSW, LMSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 473864
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28247-3864
Mailing Address - Country:US
Mailing Address - Phone:704-412-1896
Mailing Address - Fax:
Practice Address - Street 1:14969 SANTA LUCIA DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3382
Practice Address - Country:US
Practice Address - Phone:540-577-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13362104100000X
AL4680G104100000X
NCP014226104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker