Healthcare Provider Details

I. General information

NPI: 1124689583
Provider Name (Legal Business Name): KENIA GILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W BRIGGSMORE AVE STE I
MODESTO CA
95350-3839
US

IV. Provider business mailing address

2000 W BRIGGSMORE AVE STE I
MODESTO CA
95350-3839
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1476
  • Fax:
Mailing address:
  • Phone: 209-526-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number103689
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: