Provider Demographics
NPI:1194744797
Name:GIBBINS, JOHN D (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:GIBBINS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 EVERETT AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1761
Mailing Address - Country:US
Mailing Address - Phone:510-537-2622
Mailing Address - Fax:928-395-8087
Practice Address - Street 1:4026 EVERETT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1761
Practice Address - Country:US
Practice Address - Phone:510-537-2622
Practice Address - Fax:928-395-8087
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6106103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
942954911OtherEIN
942954911OtherEIN
CAFR790AMedicare UPIN