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General NPI Number Information
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NPI Number | 1649715962
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Entity Type | Individual
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Provider Name | TROY ELDON GIBSON JR. M.A., LCPC
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Gender | Male
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Dates
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Enumeration Date | 12/21/2016
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Last Update Date | 08/08/2023
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Provider Practice Location Address
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Address Line | 3950 N LAKE SHORE DR APT 625E
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City | CHICAGO
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State | IL
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Zip | 60613-6447
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Country | US
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Telephone | 484-632-9643
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Fax |
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Provider Business Mailing Address
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Address Line | 3950 N LAKE SHORE DR APT 625E
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City | CHICAGO
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State | IL
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Zip | 60613-6447
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Country | US
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Telephone | 484-632-9643
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Fax |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 178012601
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 180012507
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License Number State | IL
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