Basic Information
| Provider Information | |||||||||
| NPI: | 1942744826 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLES | ||||||||
| FirstName: | GINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 675 IVES DAIRY RD APT 107 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331795471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546685022 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 FAIRWAY DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334411817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549473766 | ||||||||
| FaxNumber: | 9543420273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2016 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | FL | Y |
No ID Information.