Provider Demographics
NPI:1528579224
Name:GIPSON, LACRYSTAL
Entity Type:Individual
Prefix:
First Name:LACRYSTAL
Middle Name:
Last Name:GIPSON
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 1:5720 S LAKESHORE DR APT 1004
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-3931
Mailing Address - Country:US
Mailing Address - Phone:318-272-2971
Mailing Address - Fax:
Practice Address - Street 1:5720 S LAKESHORE DR APT 1004
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-3931
Practice Address - Country:US
Practice Address - Phone:318-272-2971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health