Provider Demographics
NPI:1750423059
Name:GIBSON-PETTIBON, LISA MARIE (MSW)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:GIBSON-PETTIBON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11905 GATWICK VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-4169
Mailing Address - Country:US
Mailing Address - Phone:317-910-7752
Mailing Address - Fax:
Practice Address - Street 1:5638 PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-5042
Practice Address - Country:US
Practice Address - Phone:317-247-8900
Practice Address - Fax:317-247-8935
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS3620000Medicare ID - Type Unspecified
KS17-4602Medicare ID - Type Unspecified