MEDICARE: MR. DWAYNE LEE GIBSON JR. MSW, CDCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	090176	OH

General Provider Information

NPI Number	:	1700180262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DWAYNE LEE GIBSON JR. MSW, CDCA

Provider Business Mailing Address
First Line	:	5416 GLENRIDGE DR
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-1608
Country	:	US
Telephone Number	:	419-705-2169
Fax Number	:

Provider Business Practice Location Address
First Line	:	5416 GLENRIDGE DR
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-1608
Country	:	US
Telephone Number	:	419-705-2169
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2010
Last Update Date	:	12/27/2010

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