Basic Information
| Provider Information | |||||||||
| NPI: | 1962612077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLEY | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | LEILON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 934 SW 11TH ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973654804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415747799 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4909 S COAST HWY STE 1 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973669667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415745960 | ||||||||
| FaxNumber: | 5418676548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 08/11/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1992755664 | 01 | GROUP NPI | OTHER |