Provider Demographics
NPI:1437172103
Name:NIEBUR, THOMAS P (LCPC, LMFT, CSAT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:NIEBUR
Suffix:
Gender:M
Credentials:LCPC, LMFT, CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2451
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-2451
Mailing Address - Country:US
Mailing Address - Phone:309-268-2172
Mailing Address - Fax:309-268-3649
Practice Address - Street 1:303 N HERSHEY RD
Practice Address - Street 2:SUITE# 01
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3576
Practice Address - Country:US
Practice Address - Phone:309-268-3529
Practice Address - Fax:309-268-2323
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
180001431101YP2500X
IL166000183106H00000X
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
05732028OtherBLUE CROSS BLUE SHIELD