Provider Demographics
NPI:1407078322
Name:GIBBONS, TRACI A (BA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:A
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6024 SCHUSTRICH RD
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:OH
Mailing Address - Zip Code:44255
Mailing Address - Country:US
Mailing Address - Phone:330-274-0514
Mailing Address - Fax:
Practice Address - Street 1:520 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266
Practice Address - Country:US
Practice Address - Phone:330-296-5552
Practice Address - Fax:330-296-6126
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator