Provider Demographics
NPI:1063997443
Name:RICHARD, ALISA KAYE GIBSON (LCMHCA)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:KAYE GIBSON
Last Name:RICHARD
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 MCCLINTOCK RD UNIT 232
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5159
Mailing Address - Country:US
Mailing Address - Phone:864-314-4988
Mailing Address - Fax:
Practice Address - Street 1:311 WILLIAMSON RD STE 103
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5967
Practice Address - Country:US
Practice Address - Phone:704-360-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14341101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor