Provider Demographics
NPI:1679207906
Name:GIBBS, LISA OLIVIA (LPC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:OLIVIA
Last Name:GIBBS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4708 RETREAT LANE
Mailing Address - Street 2:APT 191
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-7818
Mailing Address - Country:US
Mailing Address - Phone:154-047-9750
Mailing Address - Fax:
Practice Address - Street 1:4708 RETREAT LN APT 191
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-7818
Practice Address - Country:US
Practice Address - Phone:540-479-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011621101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional