Healthcare Provider Details

I. General information

NPI: 1144801721
Provider Name (Legal Business Name): ELIOTT GILLOOLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BRISTOL ST STE E103
COSTA MESA CA
92626-7906
US

IV. Provider business mailing address

PO BOX 95
LONG BEACH CA
90801-0095
US

V. Phone/Fax

Practice location:
  • Phone: 714-814-3336
  • Fax:
Mailing address:
  • Phone: 562-270-4414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number140350
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: