Doctor Name: | DR. MARK TANNER GIBSON |
NPI Number: | 1225115561 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PH.D. |
License Number: | 437 |
Business Practice Address: | 175 River View Dr Green River, WY - 829354811 |
Business Phone Number: | 3078723205 |
Business Fax Number: | 3078723207 |
Mailing Address: | 175 River View Dr, GREEN RIVER |
State: | WY |
Postal Code: | 829354811 |
Phone Number: | 3078723205 |
Fax Number: | |
NPI Enumeration Date: | 11/01/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC1900X |
License Number: | 437 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WY |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Counseling |
Taxonomy Definition: |