Healthcare Provider Details

I. General information

NPI: 1164719373
Provider Name (Legal Business Name): GIBSON CENTER FOR BEHAVIORAL CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 S BROADVIEW ST
CAPE GIRARDEAU MO
63703-5703
US

IV. Provider business mailing address

340 S BROADVIEW ST
CAPE GIRARDEAU MO
63703-5703
US

V. Phone/Fax

Practice location:
  • Phone: 573-332-0416
  • Fax: 573-335-2698
Mailing address:
  • Phone: 573-332-0416
  • Fax: 573-335-2698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number096892
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number002005
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2001007821
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2004002713
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001113
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2009023490
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2002031993
License Number StateMO
# 8
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMO2005003649
License Number StateMO

VIII. Authorized Official

Name: RYAN ESSEX
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 573-803-4145