Provider Demographics
NPI:1427230820
Name:LISSON, GAIL LESLEY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GAIL
Middle Name:LESLEY
Last Name:LISSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 N CIRCLE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2430
Mailing Address - Country:US
Mailing Address - Phone:252-206-6930
Mailing Address - Fax:252-443-9101
Practice Address - Street 1:112 N CIRCLE DR
Practice Address - Street 2:SUITE B
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2430
Practice Address - Country:US
Practice Address - Phone:252-206-6930
Practice Address - Fax:252-443-9101
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3456103TC0700X
FLPY6958103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6001035Medicaid
NC2821266Medicare UPIN
NC2821266Medicare PIN