Basic Information
| Provider Information | |||||||||
| NPI: | 1043559487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLMAN | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HADDOCK | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 683128 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817884913 | ||||||||
| FaxNumber: | 2818941422 | ||||||||
| Practice Location | |||||||||
| Address1: | 11820 CYPRESS CORNER LN | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770651132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818941423 | ||||||||
| FaxNumber: | 2818941422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2013 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-12-5046 | TX | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1-13-14539 | TX | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.