Provider Demographics
NPI:1801049150
Name:GIBBONS, LISA C (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W GORE ST STE 405
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1049
Mailing Address - Country:US
Mailing Address - Phone:321-841-3820
Mailing Address - Fax:321-843-6836
Practice Address - Street 1:100 W GORE ST STE 405
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1049
Practice Address - Country:US
Practice Address - Phone:321-841-3820
Practice Address - Fax:321-843-6836
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7824103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGM409ZMedicare PIN