Active NPI
Gillian Tibbetts, PSYD
- Clinical Psychologist
- Prior Lake, MN
National Provider Identifier
1891348231
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 6599
- Practice address
- 16180 Hastings Ave SE Ste 205
Prior Lake, MN 55372-9228 - Phone
- (952) 443-4600
- NPI assigned
- Jul 23, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 6599 | MN | Primary |
Addresses
Primary practice location
16180 Hastings Ave SE Ste 205
Prior Lake, MN 55372-9228
Mailing address
1772 Stieger Lake LN
Victoria, MN 55386-7723
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6599 | MN | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1563840000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1601596800000",
"number": "1891348231",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1772 STIEGER LAKE LN",
"city": "VICTORIA",
"state": "MN",
"postal_code": "553867723"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "16180 HASTINGS AVE SE STE 205",
"city": "PRIOR LAKE",
"state": "MN",
"postal_code": "553729228",
"telephone_number": "952-443-4600"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TIBBETTS",
"first_name": "GILLIAN",
"name_prefix": "Dr.",
"credential": "PSYD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-07-23",
"last_updated": "2020-10-02",
"certification_date": "2020-10-02",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MN",
"license": "6599",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Prior Lake, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 2, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.