Basic Information
| Provider Information | |||||||||
| NPI: | 1225226434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILBERT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MA, LMFT, CHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4396 HOLLAND RD | ||||||||
| Address2: | |||||||||
| City: | CLARKSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956125070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613106648 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4396 HOLLAND RD | ||||||||
| Address2: | |||||||||
| City: | CLARKSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956125070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613106648 | ||||||||
| FaxNumber: | 6619405452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2007 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MFC 37413 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP1600X | N | Behavioral Health & Social Service Providers | Counselor | Pastoral | 101YP2500X | MFC 37413 | CA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 225A00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Music Therapist | 106H00000X | MFC 37413 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 37413 | 01 | CA | BBSE | OTHER | 14407150 | 01 | CAQH | OTHER |