Provider Demographics
NPI:1144328196
Name:GIBILIE, LISA ANGELA (LAC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANGELA
Last Name:GIBILIE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20422 BEACH BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-4373
Mailing Address - Country:US
Mailing Address - Phone:714-313-5506
Mailing Address - Fax:714-441-7983
Practice Address - Street 1:20422 BEACH BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-4373
Practice Address - Country:US
Practice Address - Phone:714-313-5506
Practice Address - Fax:714-441-7983
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7324171100000X
CAAT2994225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant