Provider Demographics
NPI:1750740718
Name:GIBSON, LENWOOD JR (PHD, BCBA-D, LBA)
Entity type:Individual
Prefix:DR
First Name:LENWOOD
Middle Name:
Last Name:GIBSON
Suffix:JR
Gender:M
Credentials:PHD, BCBA-D, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CHENANGO DR
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-3720
Mailing Address - Country:US
Mailing Address - Phone:508-579-3068
Mailing Address - Fax:
Practice Address - Street 1:104 CHENANGO DR
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-3720
Practice Address - Country:US
Practice Address - Phone:508-579-3068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001113103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst