Provider Demographics
NPI:1073627477
Name:TAN, GABRIEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1259 MISTY LAKE COURT
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77498-5613
Mailing Address - Country:US
Mailing Address - Phone:346-702-8936
Mailing Address - Fax:713-794-7674
Practice Address - Street 1:9525 KATY FREEWAY, STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024
Practice Address - Country:US
Practice Address - Phone:346-702-8936
Practice Address - Fax:713-794-7674
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24013103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033150602Medicaid