MEDICARE: MR. TROY ELDON GIBSON JR. M.A., LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	178012601	IL
2	101YM0800X	Mental Health Counselor	180012507	IL

General Provider Information

NPI Number	:	1649715962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TROY ELDON GIBSON JR. M.A., LCPC

Provider Business Mailing Address
First Line	:	3950 N LAKE SHORE DR APT 625E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-6447
Country	:	US
Telephone Number	:	484-632-9643
Fax Number	:

Provider Business Practice Location Address
First Line	:	3950 N LAKE SHORE DR APT 625E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-6447
Country	:	US
Telephone Number	:	484-632-9643
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2016
Last Update Date	:	08/08/2023

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