Provider Demographics
NPI:1154520518
Name:GIBSON, KENNETH MARVIN (PC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MARVIN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2231 BROAD BLVD
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-1411
Mailing Address - Country:US
Mailing Address - Phone:800-363-9886
Mailing Address - Fax:330-922-9977
Practice Address - Street 1:2231 BROAD BLVD
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-1411
Practice Address - Country:US
Practice Address - Phone:800-363-9886
Practice Address - Fax:330-922-9977
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC4872101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor