=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083433957
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALISA GAIL GANT-GIBBS LCSWA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2024
-----------------------------------------------------
Last Update Date | 10/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4805 GREEN RD STE 103
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27616-2848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-872-6220
-----------------------------------------------------
Fax | 919-872-6223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1636 FROG HOLLOW WAY
-----------------------------------------------------
City | WAKE FOREST
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27587-4330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P021416
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------