Provider Demographics
NPI:1497926356
Name:GIBBS, LISA J (MA, CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:J
Last Name:GIBBS
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 MCCULLOCH BLVD N
Mailing Address - Street 2:STE. 100
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6559
Mailing Address - Country:US
Mailing Address - Phone:928-854-5368
Mailing Address - Fax:928-854-4462
Practice Address - Street 1:1760 MCCULLOCH BLVD N
Practice Address - Street 2:STE. 100
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6559
Practice Address - Country:US
Practice Address - Phone:928-854-5368
Practice Address - Fax:928-854-4462
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA0075231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist