Healthcare Provider Details

I. General information

NPI: 1184559726
Provider Name (Legal Business Name): CARLISSA GIPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21025 N 8TH WAY
PHOENIX AZ
85024-4204
US

IV. Provider business mailing address

21025 N 8TH WAY
PHOENIX AZ
85024-4204
US

V. Phone/Fax

Practice location:
  • Phone: 602-888-8787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number25-414653
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: