Provider Demographics
NPI:1720413321
Name:LIN, JUN-CHIH GISELA (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUN-CHIH
Middle Name:GISELA
Last Name:LIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:GISELA
Other - Middle Name:
Other - Last Name:LIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3904 PUFFIN WAY
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-6265
Mailing Address - Country:US
Mailing Address - Phone:979-575-6285
Mailing Address - Fax:979-690-0860
Practice Address - Street 1:1401 SANDIA PLZ
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-4356
Practice Address - Country:US
Practice Address - Phone:979-314-9698
Practice Address - Fax:979-314-9698
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25111103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4034530Medicaid