Provider Demographics
NPI:1578962742
Name:GIBBONS, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOSHUA
Other - Middle Name:
Other - Last Name:TRUMBULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1660 E ROSEVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3988
Mailing Address - Country:US
Mailing Address - Phone:916-784-4000
Mailing Address - Fax:
Practice Address - Street 1:1660 E ROSEVILLE PKWY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3988
Practice Address - Country:US
Practice Address - Phone:916-784-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA155112106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist