Healthcare Provider Details

I. General information

NPI: 1962345397
Provider Name (Legal Business Name): CRICKET PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CRICKET GIBB

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE UNIT L500
NORMAL IL
61761-3551
US

IV. Provider business mailing address

2000 JACOBSSEN DR
NORMAL IL
61761-6277
US

V. Phone/Fax

Practice location:
  • Phone: 309-452-0069
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: