Provider Demographics
NPI:1336299478
Name:GIBBONS, HEIDI A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:A
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WI
Mailing Address - Zip Code:53525-9493
Mailing Address - Country:US
Mailing Address - Phone:608-290-0842
Mailing Address - Fax:
Practice Address - Street 1:3506 N US HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0726
Practice Address - Country:US
Practice Address - Phone:608-757-5859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7154-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40990700Medicaid
WI000084280Medicare ID - Type UnspecifiedSEQUENCE NUMBER 0031