MEDICARE: SHAWANA GIBSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1629407101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWANA GIBSON

Provider Business Mailing Address
First Line	:	1 TIMES SQ
Second Line	:	APT 101
City	:	ELGIN
State	:	IL
Zip	:	60120-8605
Country	:	US
Telephone Number	:	224-238-7118
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 TIMES SQ
Second Line	:	APT 101
City	:	ELGIN
State	:	IL
Zip	:	60120-8605
Country	:	US
Telephone Number	:	224-238-7118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	11/05/2013

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Directions to “ SHAWANA GIBSON ” Practice Location

Language	Start Address	Practice Location

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