Provider Demographics
NPI:1801804695
Name:GIBSON, THOMAS HOWARD (PH D)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:HOWARD
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9834 GENESEE AVE
Mailing Address - Street 2:STE 321
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1216
Mailing Address - Country:US
Mailing Address - Phone:858-623-0131
Mailing Address - Fax:858-623-0131
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:STE 321
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1216
Practice Address - Country:US
Practice Address - Phone:858-623-0131
Practice Address - Fax:858-623-0131
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8528103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
W17137Medicare UPIN
WCP8528AMedicare ID - Type Unspecified