Provider Demographics
NPI:1760536668
Name:GIBBONS, ASHLEY L (PT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:L
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 THEODORE ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-2443
Mailing Address - Country:US
Mailing Address - Phone:815-724-0835
Mailing Address - Fax:815-724-0845
Practice Address - Street 1:600 THEODORE ST
Practice Address - Street 2:SUITE 6
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-2443
Practice Address - Country:US
Practice Address - Phone:815-724-0835
Practice Address - Fax:815-724-0845
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014498225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619980OtherBCBS OF IL