Provider Demographics
NPI:1770158792
Name:CONNECTIVE CLINICAL COUNSELING
Entity type:Organization
Organization Name:CONNECTIVE CLINICAL COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPCC, LICDC
Authorized Official - Phone:740-247-5463
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:OH
Mailing Address - Zip Code:45779-0134
Mailing Address - Country:US
Mailing Address - Phone:740-247-5463
Mailing Address - Fax:
Practice Address - Street 1:2377 FOURTH STREET
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:OH
Practice Address - Zip Code:45779
Practice Address - Country:US
Practice Address - Phone:740-247-5463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0439139Medicaid