Provider Demographics
NPI:1609356906
Name:GIBSON, ZACHARY MICHAEL
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:MICHAEL
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 DUANE ST APT 2D
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4371
Mailing Address - Country:US
Mailing Address - Phone:618-604-1603
Mailing Address - Fax:
Practice Address - Street 1:1548 BOND ST STE 114
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563
Practice Address - Country:US
Practice Address - Phone:630-717-9408
Practice Address - Fax:630-596-8496
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011683101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional