Provider Demographics
NPI:1912418039
Name:GAULT, LISA ANN
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:GAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:CLANCY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1085 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1955
Mailing Address - Country:US
Mailing Address - Phone:573-756-5363
Mailing Address - Fax:573-756-4557
Practice Address - Street 1:1085 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1955
Practice Address - Country:US
Practice Address - Phone:573-756-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker