Provider Demographics
NPI:1851904874
Name:GAVIN, THECLA A (MAC, NCC, LPC)
Entity Type:Individual
Prefix:
First Name:THECLA
Middle Name:A
Last Name:GAVIN
Suffix:
Gender:F
Credentials:MAC, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SW WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1406
Mailing Address - Country:US
Mailing Address - Phone:309-676-2400
Mailing Address - Fax:309-676-6022
Practice Address - Street 1:330 SW WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1406
Practice Address - Country:US
Practice Address - Phone:309-676-2400
Practice Address - Fax:309-676-6022
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016210101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health