Healthcare Provider Details

I. General information

NPI: 1891348231
Provider Name (Legal Business Name): GILLIAN TIBBETTS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16180 HASTINGS AVE SE STE 205
PRIOR LAKE MN
55372-9228
US

IV. Provider business mailing address

1772 STIEGER LAKE LN
VICTORIA MN
55386-7723
US

V. Phone/Fax

Practice location:
  • Phone: 952-443-4600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6599
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: