Provider Demographics
NPI:1043435720
Name:GIBSON, LESLIE A (PHD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 SAW MILL RIVER RD STE 1F1
Mailing Address - Street 2:
Mailing Address - City:ARDSLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10502-2143
Mailing Address - Country:US
Mailing Address - Phone:914-478-2128
Mailing Address - Fax:
Practice Address - Street 1:547 SAW MILL RIVER RD STE 1F1
Practice Address - Street 2:
Practice Address - City:ARDSLEY
Practice Address - State:NY
Practice Address - Zip Code:10502-2143
Practice Address - Country:US
Practice Address - Phone:914-478-2128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014201-1103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent