Provider Demographics
NPI:1619513470
Name:GIBSON, ANNETTE (CDCA)
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 RYDALMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-1352
Mailing Address - Country:US
Mailing Address - Phone:216-716-9998
Mailing Address - Fax:
Practice Address - Street 1:16001 HOLMES AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-2460
Practice Address - Country:US
Practice Address - Phone:216-352-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.171746101YA0400X
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)