Healthcare Provider Details

I. General information

NPI: 1184486201
Provider Name (Legal Business Name): DANIEL LAWRENCE GILLILAND SUDCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 01/24/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 BEACH COURT
LOTUS CA
95633
US

IV. Provider business mailing address

PO BOX 1666
PLACERVILLE CA
95667-1666
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-7252
  • Fax:
Mailing address:
  • Phone: 530-344-4544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10946
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: