Provider Demographics
NPI:1346553419
Name:GIBBONS BLACK, GRETCHEN (CT)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:GIBBONS BLACK
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 IHLE DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-6022
Mailing Address - Country:US
Mailing Address - Phone:513-535-6315
Mailing Address - Fax:
Practice Address - Street 1:271 IHLE DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-6022
Practice Address - Country:US
Practice Address - Phone:513-535-6315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0900427-TRE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor