Provider Demographics
NPI:1619669603
Name:GIBSON, LAKISHA (CHW)
Entity type:Individual
Prefix:
First Name:LAKISHA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 MAIN ST STE 600
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-5368
Mailing Address - Country:US
Mailing Address - Phone:512-817-4248
Mailing Address - Fax:888-473-2963
Practice Address - Street 1:777 MAIN ST STE 600
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5368
Practice Address - Country:US
Practice Address - Phone:512-817-4248
Practice Address - Fax:888-473-2963
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15908251B00000X, 251B00000X, 171M00000X, 172V00000X
104100000X, 172V00000X, 385HR2055X, 106S00000X, 261QM0850X, 261QC1500X, 261QM0855X, 385HR2055X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, ChildGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health