Healthcare Provider Details

I. General information

NPI: 1225115561
Provider Name (Legal Business Name): MARK TANNER GIBSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 11/08/2025
Certification Date: 11/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 HILLTOP DR STE 103
ROCK SPRINGS WY
82901-5858
US

IV. Provider business mailing address

1208 HILLTOP DR STE 103
ROCK SPRINGS WY
82901-5858
US

V. Phone/Fax

Practice location:
  • Phone: 307-212-8064
  • Fax: 307-224-2128
Mailing address:
  • Phone: 307-212-8064
  • Fax: 307-224-2128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number437
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number437
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number437
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: