MEDICARE: AGLAED M GILLIS LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	MSW004742	GA

General Provider Information

NPI Number	:	1376809780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGLAED M GILLIS LMSW

Provider Business Mailing Address
First Line	:	P.O. BOX 73
Second Line	:
City	:	FORT BELVOIR
State	:	VA
Zip	:	22060-0073
Country	:	US
Telephone Number	:	404-626-2048
Fax Number	:

Provider Business Practice Location Address
First Line	:	5815 20TH ST
Second Line	:	BLDG 213 SUITE 211
City	:	FORT BELVOIR
State	:	VA
Zip	:	22060-5523
Country	:	US
Telephone Number	:	703-805-5588
Fax Number	:	703-805-1065

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2012
Last Update Date	:	04/10/2012

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