Provider Demographics
NPI:1558044982
Name:GIPSON, LEONDRA LATRICE (ALC)
Entity Type:Individual
Prefix:
First Name:LEONDRA
Middle Name:LATRICE
Last Name:GIPSON
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:LEONDRA
Other - Middle Name:LATRICE
Other - Last Name:LAWERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED, NCC
Mailing Address - Street 1:3231 FERNWAY DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-1816
Mailing Address - Country:US
Mailing Address - Phone:334-538-8406
Mailing Address - Fax:
Practice Address - Street 1:5510 WARES FERRY RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-2111
Practice Address - Country:US
Practice Address - Phone:334-322-4437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04575101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health