Provider Demographics
NPI:1881068211
Name:GIBSON, CHERYL (PHD)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 CLAIRMONT RD NE STE B
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-1043
Mailing Address - Country:US
Mailing Address - Phone:404-636-1457
Mailing Address - Fax:404-636-7449
Practice Address - Street 1:1814 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3405
Practice Address - Country:US
Practice Address - Phone:404-636-1457
Practice Address - Fax:404-636-7449
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC005156101YP2500X
GALPC009302101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional