Provider Demographics
NPI:1881922284
Name:MARCIA S. GIBSON, PSY.D AND ASSOCIATES, P. C..
Entity type:Organization
Organization Name:MARCIA S. GIBSON, PSY.D AND ASSOCIATES, P. C..
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-759-4000
Mailing Address - Street 1:404 W BOUGHTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1898
Mailing Address - Country:US
Mailing Address - Phone:630-759-4000
Mailing Address - Fax:630-759-5220
Practice Address - Street 1:404 W BOUGHTON RD STE B
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1898
Practice Address - Country:US
Practice Address - Phone:630-759-4000
Practice Address - Fax:630-759-5220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007322261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1346434883OtherNATIONAL PROVIDER IDENTIFICATION ENUMERATOR, TYPE 1