Provider Demographics
NPI:1225115561
Name:GIBSON, MARK TANNER (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TANNER
Last Name:GIBSON
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 1:2632 FOOTHILL BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4757
Mailing Address - Country:US
Mailing Address - Phone:307-212-8064
Mailing Address - Fax:307-224-2128
Practice Address - Street 1:2632 FOOTHILL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4757
Practice Address - Country:US
Practice Address - Phone:307-212-8064
Practice Address - Fax:307-224-2128
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY437103TC0700X, 103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling