Provider Demographics
NPI:1609362490
Name:GIBSON, CHERYL K (LPCA, LCADC)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:K
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LPCA, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 HIGHWAY 638 STE 1
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-7289
Mailing Address - Country:US
Mailing Address - Phone:606-598-0070
Mailing Address - Fax:844-273-1765
Practice Address - Street 1:375 TOWN BRANCH RD STE 2
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-1326
Practice Address - Country:US
Practice Address - Phone:606-598-0070
Practice Address - Fax:844-273-1765
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2023-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY242173101YM0800X
KY248391101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100646500Medicaid