Provider Demographics
NPI:1588176200
Name:GIBBONS, SHANE RYAN (PHD)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:RYAN
Last Name:GIBBONS
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:MAIL LOCATION 0034
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45221-0034
Mailing Address - Country:US
Mailing Address - Phone:513-556-0648
Mailing Address - Fax:513-556-2302
Practice Address - Street 1:225 CALHOUN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-1587
Practice Address - Country:US
Practice Address - Phone:513-556-0648
Practice Address - Fax:513-556-2302
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.07648103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling