Provider Demographics
NPI:1881885788
Name:GIBSON, LISA TARA (CSAC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:TARA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:TARA
Other - Last Name:PASKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSAC
Mailing Address - Street 1:230 W WELLS ST STE 214
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1866
Mailing Address - Country:US
Mailing Address - Phone:414-223-3815
Mailing Address - Fax:414-223-3817
Practice Address - Street 1:230 W WELLS ST STE 214
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-1866
Practice Address - Country:US
Practice Address - Phone:414-223-3815
Practice Address - Fax:414-223-3817
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10791-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)