Provider Demographics
NPI:1114689205
Name:GIBBONS, SUSAN DIANE (MA COUNSELING INTERN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:MA COUNSELING INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-2331
Mailing Address - Country:US
Mailing Address - Phone:224-545-1229
Mailing Address - Fax:
Practice Address - Street 1:1616 E ROOSEVELT RD STE 8
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-6850
Practice Address - Country:US
Practice Address - Phone:630-588-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health