Provider Demographics
NPI:1306530845
Name:GIBSON PEDIATRIC SPEECH SERVICES
Entity type:Organization
Organization Name:GIBSON PEDIATRIC SPEECH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP/L
Authorized Official - Phone:309-220-8030
Mailing Address - Street 1:106 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIDLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61744-9241
Mailing Address - Country:US
Mailing Address - Phone:309-220-8030
Mailing Address - Fax:
Practice Address - Street 1:106 E 7TH ST
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:IL
Practice Address - Zip Code:61744-9241
Practice Address - Country:US
Practice Address - Phone:309-220-8030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-07
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty