Healthcare Provider Details

I. General information

NPI: 1609421049
Provider Name (Legal Business Name): CAMILLE C GIBSON MFT MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAMILLE C GIBSON

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 N GRANT AVE STE 250
COLUMBUS OH
43215-2855
US

IV. Provider business mailing address

434 EASTLAND RD
BEREA OH
44017-1217
US

V. Phone/Fax

Practice location:
  • Phone: 440-260-8300
  • Fax:
Mailing address:
  • Phone: 440-234-2006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162710
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM.1900147-TRNE
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM2000142
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: