Provider Demographics
NPI:1588928451
Name:GIBBONS, MATTHEW TIMOTHY (PSYD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TIMOTHY
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15615 ALTON PKWY
Mailing Address - Street 2:STE 230
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-7306
Mailing Address - Country:US
Mailing Address - Phone:773-320-0898
Mailing Address - Fax:
Practice Address - Street 1:7700 IRVINE CENTER DR
Practice Address - Street 2:STE 800
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3047
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27185103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist