Healthcare Provider Details

I. General information

NPI: 1457934762
Provider Name (Legal Business Name): DEIDRA L BIBBS PHD, HSPP, NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6127 S UNIVERSITY AVE STE 1090
CHICAGO IL
60637-7425
US

IV. Provider business mailing address

7658 S ABERDEEN ST APT 2
CHICAGO IL
60620-3666
US

V. Phone/Fax

Practice location:
  • Phone: 773-830-4005
  • Fax:
Mailing address:
  • Phone: 773-294-2528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number40952
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20043964B
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071011463
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: