Provider Demographics
NPI:1700400587
Name:GIBSON, LISA M
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:GOSSERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-405
Mailing Address - Street 1:2360 E PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5356
Mailing Address - Country:US
Mailing Address - Phone:307-778-7349
Mailing Address - Fax:
Practice Address - Street 1:2509 RESEARCH BLVD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-8108
Practice Address - Country:US
Practice Address - Phone:307-214-7655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical