1639398258 NPI number — MARY JO GILL LMFT

Table of content: MARY JO GILL LMFT (NPI 1639398258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639398258 NPI number — MARY JO GILL LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILL
Provider First Name:
MARY JO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
MARY
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MFT-I
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639398258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1810 E SAHARA AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89104-3707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-706-7855
Provider Business Mailing Address Fax Number:
702-543-5109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1810 E SAHARA AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89104-3707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-706-7855
Provider Business Practice Location Address Fax Number:
702-543-5109
Provider Enumeration Date:
04/24/2007

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: 106H00000X , with the licence number:  MI0795 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100511740 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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