Healthcare Provider Details

I. General information

NPI: 1629632591
Provider Name (Legal Business Name): CURTIS WILSON GILLIS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 NE 13TH ST
FORT LAUDERDALE FL
33304-2012
US

IV. Provider business mailing address

919 NE 13TH ST
FORT LAUDERDALE FL
33304-2012
US

V. Phone/Fax

Practice location:
  • Phone: 954-763-2030
  • Fax: 954-467-5844
Mailing address:
  • Phone: 954-763-2030
  • Fax: 954-467-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW13875
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13875
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: