Provider Demographics
NPI:1164719373
Name:GIBSON CENTER FOR BEHAVIORAL CHANGE
Entity Type:Organization
Organization Name:GIBSON CENTER FOR BEHAVIORAL CHANGE
Other - Org Name:HILLCREST COUNSELING ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ESSEX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-803-4145
Mailing Address - Street 1:340 S BROADVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5703
Mailing Address - Country:US
Mailing Address - Phone:573-332-0416
Mailing Address - Fax:573-335-2698
Practice Address - Street 1:340 S BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5703
Practice Address - Country:US
Practice Address - Phone:573-332-0416
Practice Address - Fax:573-335-2698
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIBSON RECOVERY CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-08
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009023490101YM0800X
MO2001007821101YM0800X
MO2004002713101YM0800X
MO001113101YM0800X
MO002005101YM0800X
MO20020319931041C0700X
MOMO20050036492084P0800X
MO096892364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty