Provider Demographics
NPI:1376686394
Name:GIBSON, CARLA INGRID (PHD)
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:INGRID
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 E A ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2217
Mailing Address - Country:US
Mailing Address - Phone:307-232-6096
Mailing Address - Fax:307-232-6098
Practice Address - Street 1:1522 E A ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2217
Practice Address - Country:US
Practice Address - Phone:307-232-6096
Practice Address - Fax:307-232-6098
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2014-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY447103TC0700X, 103TB0200X, 103TP2701X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW24327Medicare UPIN