Healthcare Provider Details

I. General information

NPI: 1710634704
Provider Name (Legal Business Name): MAUREEN A GEBHARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3716 W BRIGHTON AVE
PEORIA IL
61615-2938
US

IV. Provider business mailing address

6526 N LEXINGTON DR
PEORIA IL
61614-2925
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-7755
  • Fax: 309-692-2262
Mailing address:
  • Phone: 309-336-0228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.017220
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: