Healthcare Provider Details

I. General information

NPI: 1477939452
Provider Name (Legal Business Name): CHRISTOPHER GIBSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 WESTLAKE DR SUITE 105
WEST LAKE HILLS TX
78746-5394
US

IV. Provider business mailing address

21600 OXNARD ST SUITE 1800
WOODLAND HILLS CA
91367-4976
US

V. Phone/Fax

Practice location:
  • Phone: 512-813-7272
  • Fax:
Mailing address:
  • Phone: 818-345-2345
  • Fax: 818-758-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-15-19308
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: