1295801900 NPI number — DR. BERTRAM ST CYR LINARD GIBBES PHD PSYCHOLOGIST

Table of content: DR. BERTRAM ST CYR LINARD GIBBES PHD PSYCHOLOGIST (NPI 1295801900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295801900 NPI number — DR. BERTRAM ST CYR LINARD GIBBES PHD PSYCHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBBES
Provider First Name:
BERTRAM
Provider Middle Name:
ST CYR LINARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD PSYCHOLOGIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295801900
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
481A KINGSTOWN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKEFIELD
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02879-3607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-782-1667
Provider Business Mailing Address Fax Number:
401-782-1669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
481A KINGSTOWN RD
Provider Second Line Business Practice Location Address:
SUITE D4
Provider Business Practice Location Address City Name:
WAKEFIELD
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02879-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-782-1667
Provider Business Practice Location Address Fax Number:
401-782-1669
Provider Enumeration Date:
11/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  511 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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