Provider Demographics
NPI:1184774275
Name:GIBSON CENTER FOR BEHAVIORAL CHANGE
Entity type:Organization
Organization Name:GIBSON CENTER FOR BEHAVIORAL CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ESSEX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-803-4145
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-1267
Mailing Address - Country:US
Mailing Address - Phone:573-332-0416
Mailing Address - Fax:573-334-0312
Practice Address - Street 1:1112 LINDEN ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-7707
Practice Address - Country:US
Practice Address - Phone:573-332-0416
Practice Address - Fax:573-334-0312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO30567335324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO863112702Medicaid
MO105152OtherBLUE CROSSBLUE SHIELD