MEDICARE: ALICE JEAN GIBSON 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	101YP2500X	Professional Counselor	180.006485	IL

General Provider Information

NPI Number	:	1659511426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICE JEAN GIBSON LCPC

Provider Business Mailing Address
First Line	:	3146 W 85TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-3429
Country	:	US
Telephone Number	:	773-297-2401
Fax Number	:

Provider Business Practice Location Address
First Line	:	9415 S WESTERN AVE
Second Line	:	SUITE 117
City	:	CHICAGO
State	:	IL
Zip	:	60643-6700
Country	:	US
Telephone Number	:	773-297-2401
Fax Number	:

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

Provider Enumeration Date	:	03/05/2009
Last Update Date	:	10/06/2016

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