Provider Demographics
NPI:1073541298
Name:GIBSON, ELIZABETH (PSYD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1785
Mailing Address - Country:US
Mailing Address - Phone:513-245-3107
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:260 STETSON ST STE 3200
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2472
Practice Address - Country:US
Practice Address - Phone:513-558-7700
Practice Address - Fax:513-558-5449
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6378103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY184607OtherMEDICARE GROUP NUMBER
KY610661458OtherFEDERAL TAX ID NUMBER