Healthcare Provider Details

I. General information

NPI: 1043753569
Provider Name (Legal Business Name): REZAL GILLIES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2016
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5849 CROCKER ST
LOS ANGELES CA
90003-1311
US

IV. Provider business mailing address

5849 CROCKER ST
LOS ANGELES CA
90003-1311
US

V. Phone/Fax

Practice location:
  • Phone: 323-234-4445
  • Fax: 323-234-4477
Mailing address:
  • Phone: 323-234-4445
  • Fax: 323-234-4477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number97053
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: