Provider Demographics
NPI:1124481312
Name:GIBBONS, MARY KATHLEEN (LCPC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLEEN
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHLEEN
Other - Last Name:KIBORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W STE 204
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-398-9850
Mailing Address - Fax:618-398-9849
Practice Address - Street 1:2900 FRANK SCOTT PKWY W STE 204
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-398-9850
Practice Address - Fax:618-398-9849
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014044614101YP2500X
IL180010634101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional