Provider Demographics
NPI:1629668165
Name:MCKELVY-GIBBONS, KATIE ANN (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN
Last Name:MCKELVY-GIBBONS
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1318
Mailing Address - Country:US
Mailing Address - Phone:618-920-6119
Mailing Address - Fax:618-288-4669
Practice Address - Street 1:200 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1415
Practice Address - Country:US
Practice Address - Phone:618-920-6119
Practice Address - Fax:618-288-4669
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.014311101YP2500X
IL180.015303101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional