Basic Information
| Provider Information | |||||||||
| NPI: | 1063771335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | BRUCE | ||||||||
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| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ST VINCENT DIVE | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94903 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 SAINT VINCENTS DR | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949031504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155072000 | ||||||||
| FaxNumber: | 4154920842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2012 | ||||||||
| LastUpdateDate: | 05/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 66067 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1538223300 | 01 | CA | MEDICAL | OTHER |