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General NPI Number Information
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NPI Number | 1124481312
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Entity Type | Individual
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Provider Name | MARY KATHLEEN GIBBONS L.C.P.C
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Gender | Female
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Dates
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Enumeration Date | 04/04/2016
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Last Update Date | 10/31/2024
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Provider Practice Location Address
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Address Line | 2900 FRANK SCOTT PKWY W STE 204
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City | BELLEVILLE
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State | IL
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Zip | 62223-5000
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Country | US
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Telephone | 618-398-9850
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Fax | 618-398-9849
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Provider Business Mailing Address
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Address Line | 2900 FRANK SCOTT PKWY W STE 204
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City | BELLEVILLE
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State | IL
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Zip | 62223-5000
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Country | US
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Telephone | 618-398-9850
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Fax | 618-398-9849
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 2014044614
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180010634
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 180010634
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License Number State | IL
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