Basic Information
Provider Information | |||||||||
NPI: | 1023552833 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GILMORE | ||||||||
FirstName: | BRITTANY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MORGAN | ||||||||
OtherFirstName: | BRITTANY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1234 EMPIRE ST STE 1500 | ||||||||
Address2: |   | ||||||||
City: | FAIRFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 945335711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074264746 | ||||||||
FaxNumber: | 7074194952 | ||||||||
Practice Location | |||||||||
Address1: | 1234 EMPIRE ST STE 1500 | ||||||||
Address2: |   | ||||||||
City: | FAIRFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 945335711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074264746 | ||||||||
FaxNumber: | 7074194952 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2016 | ||||||||
LastUpdateDate: | 02/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 108854 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 247200000X | RBT-15-11530 | CA | N |   | Technologists, Technicians & Other Technical Service Providers | Technician, Other |   | 106H00000X | 131293 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.