Provider Demographics
NPI:1417204413
Name:GIBSON, JULIA NICOLE
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:NICOLE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 E WASHINGTON ST STE A4
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1612
Mailing Address - Country:US
Mailing Address - Phone:309-242-6527
Mailing Address - Fax:
Practice Address - Street 1:2416 E WASHINGTON ST STE A4
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-1612
Practice Address - Country:US
Practice Address - Phone:309-242-6527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional