Healthcare Provider Details

I. General information

NPI: 1811077183
Provider Name (Legal Business Name): ROBERT GWYN GIBBY JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 ROLLING HILLS DR SUITE 200
RICHMOND VA
23229-5011
US

IV. Provider business mailing address

PO BOX 478
MIDLOTHIAN VA
23113-0478
US

V. Phone/Fax

Practice location:
  • Phone: 804-249-8302
  • Fax:
Mailing address:
  • Phone: 804-794-8171
  • Fax: 804-794-3787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810000686
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: