Provider Demographics
NPI:1538525845
Name:GIBSON, ELISE KATHRYN (LMSW)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:KATHRYN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 W 133RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-3301
Mailing Address - Country:US
Mailing Address - Phone:212-803-2850
Mailing Address - Fax:
Practice Address - Street 1:169 W 133RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-3301
Practice Address - Country:US
Practice Address - Phone:212-803-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095018-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical