Provider Demographics
NPI:1346768306
Name:GIPSON, KESHIA
Entity type:Individual
Prefix:
First Name:KESHIA
Middle Name:
Last Name:GIPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KESHIA
Other - Middle Name:
Other - Last Name:TEVERBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 S DUNTON AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3111
Mailing Address - Country:US
Mailing Address - Phone:1847-506-6306
Mailing Address - Fax:
Practice Address - Street 1:400 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1868
Practice Address - Country:US
Practice Address - Phone:847-506-6306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2014235103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool