Healthcare Provider Details

I. General information

NPI: 1124481312
Provider Name (Legal Business Name): MARY KATHLEEN GIBBONS L.C.P.C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY KATHLEEN KIBORT

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 FRANK SCOTT PKWY W STE 204
BELLEVILLE IL
62223-5000
US

IV. Provider business mailing address

2900 FRANK SCOTT PKWY W STE 204
BELLEVILLE IL
62223-5000
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-9850
  • Fax: 618-398-9849
Mailing address:
  • Phone: 618-398-9850
  • Fax: 618-398-9849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180010634
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2014044614
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180010634
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: