Provider Demographics
NPI:1568880821
Name:GIBSON, LACY II
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:GIBSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 W. CHEYENNE AVE.
Mailing Address - Street 2:SUITE 130
Mailing Address - City:N. LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032
Mailing Address - Country:US
Mailing Address - Phone:702-570-5200
Mailing Address - Fax:702-570-5201
Practice Address - Street 1:3550 W. CHEYENNE AVE.
Practice Address - Street 2:SUITE 130
Practice Address - City:N. LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032
Practice Address - Country:US
Practice Address - Phone:702-570-5200
Practice Address - Fax:702-570-5201
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional