1336299478 NPI number — MRS. HEIDI A GIBBONS LCSW

Table of content: LIAN JELENSZKY DO (NPI 1144884552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336299478 NPI number — MRS. HEIDI A GIBBONS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBBONS
Provider First Name:
HEIDI
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336299478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
508 CHURCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53525-9493
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-290-0842
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3506 N US HIGHWAY 51
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JANESVILLE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53545-0726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-757-5859
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  7154-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40990700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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