Provider Demographics
NPI:1922234525
Name:GIBSON, JUSTIN TARRANCE
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:TARRANCE
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 BANCROFT WAY
Mailing Address - Street 2:UNIVERSITY OF CALIFORNIA, BERKELEY
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-4301
Mailing Address - Country:US
Mailing Address - Phone:256-337-9064
Mailing Address - Fax:
Practice Address - Street 1:500 PARNASSUS AVE RM 5
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2203
Practice Address - Country:US
Practice Address - Phone:415-476-1281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29025103TB0200X, 103TC0700X, 103TC1900X, 103TH0100X, 103TP2701X, 103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program