Healthcare Provider Details

I. General information

NPI: 1124885900
Provider Name (Legal Business Name): ROBERT GIPSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13193 CENTRAL AVE
CHINO CA
91710-4179
US

IV. Provider business mailing address

7353 ELLENA W UNIT 79
RANCHO CUCAMONGA CA
91730-8367
US

V. Phone/Fax

Practice location:
  • Phone: 909-464-9675
  • Fax:
Mailing address:
  • Phone: 909-730-9053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number121163
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number142029
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: