Provider Demographics
NPI:1841312931
Name:GIBSON, TASHA L (MS, CCC SLP L)
Entity type:Individual
Prefix:MRS
First Name:TASHA
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MS, CCC SLP L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 LINCOLN HWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1627
Mailing Address - Country:US
Mailing Address - Phone:708-283-0411
Mailing Address - Fax:708-283-3974
Practice Address - Street 1:3612 LINCOLN HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1627
Practice Address - Country:US
Practice Address - Phone:708-283-0411
Practice Address - Fax:708-283-3974
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist