Healthcare Provider Details

I. General information

NPI: 1578216891
Provider Name (Legal Business Name): JOANNA GILLIS LICENSED CLINICAL SOCIAL WORKER GILLIS THERAPY GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK E STE 1406
CENTURY CITY CA
90067-2017
US

IV. Provider business mailing address

2080 CENTURY PARK E STE 1406
CENTURY CITY CA
90067-2017
US

V. Phone/Fax

Practice location:
  • Phone: 424-394-0295
  • Fax:
Mailing address:
  • Phone: 424-394-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL FERNER
Title or Position: OFFICE MANAGER
Credential:
Phone: 424-394-0312