Provider Demographics
NPI:1093174096
Name:GAULT, LISA BRATTON (MMFT, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:BRATTON
Last Name:GAULT
Suffix:
Gender:F
Credentials:MMFT, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29340-4801
Mailing Address - Country:US
Mailing Address - Phone:864-490-1668
Mailing Address - Fax:
Practice Address - Street 1:6 PELHAM RIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-5935
Practice Address - Country:US
Practice Address - Phone:864-490-1668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-15-21097103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst