Provider Demographics
NPI:1699521450
Name:GIBSON, LISA (LMSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WACCABUC RD UNIT 11
Mailing Address - Street 2:
Mailing Address - City:GOLDENS BRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10526-1222
Mailing Address - Country:US
Mailing Address - Phone:914-640-0799
Mailing Address - Fax:
Practice Address - Street 1:205 WACCABUC RD UNIT 11
Practice Address - Street 2:
Practice Address - City:GOLDENS BRIDGE
Practice Address - State:NY
Practice Address - Zip Code:10526-1222
Practice Address - Country:US
Practice Address - Phone:914-640-0799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068169-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty