Provider Demographics
NPI:1528028073
Name:GIBSON, CHARLES F (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:F
Last Name:GIBSON
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 1:210 E MILLTOWN RD STE B
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-1200
Mailing Address - Country:US
Mailing Address - Phone:330-345-0955
Mailing Address - Fax:330-345-3420
Practice Address - Street 1:210 E MILLTOWN RD STE B
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-1200
Practice Address - Country:US
Practice Address - Phone:330-345-0955
Practice Address - Fax:330-345-3420
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3370103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0630893Medicaid
OH0630893Medicaid