Healthcare Provider Details

I. General information

NPI: 1528054434
Provider Name (Legal Business Name): RACHEL RODGERS GILLIS LCSW BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3686 US HIGHWAY 331 S
DEFUNIAK SPRINGS FL
32435
US

IV. Provider business mailing address

1221 W LAKEVIEW AVE
PENSACOLA FL
32501-1857
US

V. Phone/Fax

Practice location:
  • Phone: 850-892-8045
  • Fax: 850-892-8039
Mailing address:
  • Phone: 850-469-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW5373
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: