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NPI Code Detail

MEDICARE: MS. LISA MARIE GIBSON-PETTIBON MSW

MEDICARE: MS. LISA MARIE GIBSON-PETTIBON MSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst
2106S00000XBehavior Technician
3104100000XSocial Worker

General Provider Information

NPI Number : 1750423059
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. LISA MARIE GIBSON-PETTIBON MSW
Provider Business Mailing Address
First Line : 11905 GATWICK VIEW DR
Second Line :
City : FISHERS
State : IN
Zip : 46037-4169
Country : US
Telephone Number : 317-910-7752
Fax Number :
Provider Business Practice Location Address
First Line : 5638 PROFESSIONAL CIR
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46241-5042
Country : US
Telephone Number : 317-247-8900
Fax Number : 317-247-8935
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/13/2007
Last Update Date : 09/14/2022

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