Provider Demographics
NPI:1508628967
Name:GIBSON, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 HUNTERS RUN DR
Mailing Address - Street 2:
Mailing Address - City:TEGA CAY
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8339
Mailing Address - Country:US
Mailing Address - Phone:814-404-9220
Mailing Address - Fax:
Practice Address - Street 1:224 S CASWELL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3214
Practice Address - Country:US
Practice Address - Phone:704-313-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8850101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty