Provider Demographics
NPI:1629407101
Name:GIBSON, SHAWANA
Entity Type:Individual
Prefix:
First Name:SHAWANA
Middle Name:
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 1:1 TIMES SQ
Mailing Address - Street 2:APT 101
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-8605
Mailing Address - Country:US
Mailing Address - Phone:224-238-7118
Mailing Address - Fax:
Practice Address - Street 1:1 TIMES SQ
Practice Address - Street 2:APT 101
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-8605
Practice Address - Country:US
Practice Address - Phone:224-238-7118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health