NPIMap

Organization Active NPI

Marcia S. Gibson, Psy.D and Associates, P. C..

  • Adolescent and Children Mental Health Clinic/Center
  • Bolingbrook, IL
National Provider Identifier
1881922284
Registry record updated Apr 20, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adolescent and Children Mental Health Clinic/CenterTaxonomy code 261QM0855X
License
071007322 Issued in IL
Legal business name
MARCIA S. GIBSON, PSY.D AND ASSOCIATES, P. C..
Practice address
404 W Boughton Rd Ste B
Bolingbrook, IL 60440-1898
Phone
(630) 759-4000
Fax
(630) 759-5220
NPI assigned
Nov 23, 2009
Last updated
Apr 20, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 20, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Marcia Susan Gibson, PSY.D.NPI 1346434883
Title
President
Phone
(630) 759-4000

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Adult Mental Health Clinic/Center 261QM0850X 071007322 IL
Adolescent and Children Mental Health Clinic/Center 261QM0855X 071007322 IL Primary

Addresses

Primary practice location

404 W Boughton Rd Ste B
Bolingbrook, IL 60440-1898

Mailing address

404 W Boughton Rd Ste B
Bolingbrook, IL 60440-1898
Phone (630) 759-4000

Other identifiers 1

IdentifierTypeStateIssuer
1346434883OtherILNATIONAL PROVIDER IDENTIFICATION ENUMERATOR, TYPE 1

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100605000103 IL Part B Supplier - Clinic/Group Practice 2365577160 Receives reassigned benefits from 4 practitioners
Practice locations: Bolingbrook, IL

National Provider Directory

National Provider Directory

Locations

404 W Boughton Rd
Ste B
Bolingbrook, IL 60440
Phone (630) 685-4053

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1258934400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1461110400000",
    "number": "1881922284",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "404 W BOUGHTON RD STE B",
            "city": "BOLINGBROOK",
            "state": "IL",
            "postal_code": "604401898",
            "telephone_number": "630-759-4000",
            "fax_number": "630-759-5220"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "404 W BOUGHTON RD STE B",
            "city": "BOLINGBROOK",
            "state": "IL",
            "postal_code": "604401898",
            "telephone_number": "630-759-4000",
            "fax_number": "630-759-5220"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARCIA S. GIBSON, PSY.D AND ASSOCIATES, P. C..",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-11-23",
        "last_updated": "2016-04-20",
        "status": "A",
        "authorized_official_last_name": "GIBSON",
        "authorized_official_first_name": "MARCIA",
        "authorized_official_middle_name": "SUSAN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "630-759-4000",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PSY.D."
    },
    "taxonomies": [
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "IL",
            "license": "071007322",
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": "IL",
            "license": "071007322",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NATIONAL PROVIDER IDENTIFICATION ENUMERATOR, TYPE 1",
            "identifier": "1346434883",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Bolingbrook, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.