Provider Demographics
NPI:1407376056
Name:GIBBS, LAURA MICHELLE (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MICHELLE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 N STATE ROUTE 180
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:61489-9510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:507 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3201
Practice Address - Country:US
Practice Address - Phone:309-686-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-25
Last Update Date:2017-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180010383101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional