Provider Demographics
NPI:1942822440
Name:GIBSON, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BALTIMORE
Mailing Address - State:OH
Mailing Address - Zip Code:45872-1332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 W STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH BALTIMORE
Practice Address - State:OH
Practice Address - Zip Code:45872-1332
Practice Address - Country:US
Practice Address - Phone:833-216-3079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)