Healthcare Provider Details

I. General information

NPI: 1922234525
Provider Name (Legal Business Name): DR. JUSTIN TARRANCE GIBSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PARNASSUS AVE RM 5
SAN FRANCISCO CA
94143-2203
US

IV. Provider business mailing address

2222 BANCROFT WAY UNIVERSITY OF CALIFORNIA, BERKELEY
BERKELEY CA
94720-4301
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-1281
  • Fax:
Mailing address:
  • Phone: 256-337-9064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number29025
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number29025
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number29025
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number29025
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number29025
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number29025
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: