Provider Demographics
NPI:1144387820
Name:GIBEAU, PHILIP JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JOSEPH
Last Name:GIBEAU
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 KENSINGTON PLACE SOUTH
Mailing Address - Street 2:20 SOUTH LIMESTONE ST STE 340
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504
Mailing Address - Country:US
Mailing Address - Phone:937-399-1026
Mailing Address - Fax:937-325-3432
Practice Address - Street 1:20 SOUTH LIMESTONE ST STE 340
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502
Practice Address - Country:US
Practice Address - Phone:937-325-3370
Practice Address - Fax:937-325-3432
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2851103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408115Medicaid
OH0408115Medicaid