Provider Demographics
NPI:1609421049
Name:GIBSON, CAMILLE C (MFT MS)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:C
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MFT MS
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:C
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:434 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1217
Mailing Address - Country:US
Mailing Address - Phone:440-234-2006
Mailing Address - Fax:
Practice Address - Street 1:195 N GRANT AVE STE 250
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2855
Practice Address - Country:US
Practice Address - Phone:440-260-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHM.1900147-TRNE106H00000X
OHM2000142106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist