Healthcare Provider Details

I. General information

NPI: 1629274873
Provider Name (Legal Business Name): IBERTY GEDEON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 JEFFERSON ST
KANSAS CITY MO
64108-1104
US

IV. Provider business mailing address

1740 JEFFERSON ST
KANSAS CITY MO
64108-1104
US

V. Phone/Fax

Practice location:
  • Phone: 816-471-2536
  • Fax: 816-471-2521
Mailing address:
  • Phone: 816-471-2536
  • Fax: 816-471-2521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2001031944
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: