# BEACON ST. PSYCHIATRY

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- **Entity:** Organization
- **Status:** Active
- **Other names:** A Life Renewed
- **Organization subpart:** No

## Provider details

- **NPI number:** 1780460006
- **Authorized official:** MR. BRAD GIBSON MBA, MSN, APRN (CEO/OWNER)
- **Authorized official phone:** (937) 280-5711

## Contact information

- **Practice address:** 10552 SUCCESS LN STE L, CENTERVILLE, OH 45458-3664
- **Practice address phone:** (937) 280-5711
- **Mailing address:** 10552 SUCCESS LN STE L, CENTERVILLE, OH 45458-3664
- **Mailing address phone:** (937) 280-5711

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 09/01/2023
- **Last updated:** 01/24/2024