Provider Demographics
NPI:1619669603
Name:GIBSON, LAKISHA (DSHS CHW)
Entity Type:Individual
Prefix:
First Name:LAKISHA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DSHS CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 MAIN ST STE 600
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-5368
Mailing Address - Country:US
Mailing Address - Phone:682-438-3346
Mailing Address - Fax:
Practice Address - Street 1:777 MAIN ST STE 600
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5368
Practice Address - Country:US
Practice Address - Phone:682-438-3346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 174400000X, 104100000X, 225XM0800X, 251S00000X, 261QM0801X, 261QM0850X, 261QC1500X, 261QM0855X, 385HR2055X, 251S00000X
TX461116101Y00000X
TX15908172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, ChildGroup - Single Specialty
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty