Provider Demographics
NPI:1114353489
Name:GIBSON, TERA D
Entity Type:Individual
Prefix:MS
First Name:TERA
Middle Name:D
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-2727
Mailing Address - Country:US
Mailing Address - Phone:330-687-5642
Mailing Address - Fax:
Practice Address - Street 1:1047 HARTFORD AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2727
Practice Address - Country:US
Practice Address - Phone:330-687-5642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities