Provider Demographics
NPI:1427574748
Name:BIBB JR., WILLIAM THOMAS JR
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:THOMAS
Last Name:BIBB JR.
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 ANSEL RD APT 1329
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-4175
Mailing Address - Country:US
Mailing Address - Phone:216-299-7780
Mailing Address - Fax:
Practice Address - Street 1:1675 ANSEL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4181
Practice Address - Country:US
Practice Address - Phone:216-299-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161717101YA0400X, 103TA0400X, 103TH0100X, 171400000X, 171M00000X, 172V00000X, 174400000X, 1744R1102X, 174H00000X, 208D00000X, 225800000X, 261QP0904X, 251K00000X, 405300000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251K00000XAgenciesPublic Health or Welfare
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No1744R1102XOther Service ProvidersSpecialistResearch StudyGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Multi-Specialty
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH72379863Medicaid