Provider Demographics
NPI:1790253854
Name:GIBBON, LISA MICHELE (BA, BS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELE
Last Name:GIBBON
Suffix:
Gender:F
Credentials:BA, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 CARONDELET DR
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99354-3300
Mailing Address - Country:US
Mailing Address - Phone:509-531-2482
Mailing Address - Fax:
Practice Address - Street 1:1175 CARONDELET DR
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-3300
Practice Address - Country:US
Practice Address - Phone:509-531-2482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSTATE OF WASHINGTON