Provider Demographics
NPI:1215054010
Name:GERGEN, TIM ALAN (PHD)
Entity type:Individual
Prefix:DR
First Name:TIM
Middle Name:ALAN
Last Name:GERGEN
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 1:26391 GANIZA
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-3259
Mailing Address - Country:US
Mailing Address - Phone:949-851-8001
Mailing Address - Fax:949-305-4272
Practice Address - Street 1:2192 MARTIN
Practice Address - Street 2:SUITE 125
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1428
Practice Address - Country:US
Practice Address - Phone:949-851-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9765103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical