Provider Demographics
NPI:1508605437
Name:GIBSON, SANDA (DR)
Entity type:Individual
Prefix:MS
First Name:SANDA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9505 VISTA POINT DR
Mailing Address - Street 2:
Mailing Address - City:THORNVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43076-8894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1480 MANNING PKWY
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-9171
Practice Address - Country:US
Practice Address - Phone:614-888-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0602093101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty