Provider Demographics
NPI:1437465952
Name:GIBSON, GEORGE FARRELL II (BA MHP)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:FARRELL
Last Name:GIBSON
Suffix:II
Gender:M
Credentials:BA MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 HARTWELL DR
Mailing Address - Street 2:APT #7
Mailing Address - City:SAVOY
Mailing Address - State:IL
Mailing Address - Zip Code:61874-9749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:502 N MARKET ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3634
Practice Address - Country:US
Practice Address - Phone:217-373-2428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-21
Last Update Date:2010-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health