Individual
LISA JILLIAN GIBSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1708 W HAZEL ST, BOISE, ID 83702-1021
(208) 866-6852
Mailing address
1708 W HAZEL ST, BOISE, ID 83702-1021
(208) 866-6852
Taxonomy
Speciality
Code
Description
License number
State
106E00000X
Assistant Behavior Analyst
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
19190006
—
ID
Enumeration date
07/20/2019
Last updated
07/20/2019
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