Healthcare Provider Details

I. General information

NPI: 1528997558
Provider Name (Legal Business Name): DALE CARL GILLMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2487 CEDARCREST RD STE 724
ACWORTH GA
30101-2731
US

IV. Provider business mailing address

4142 BUTLER DR
CHAMBLEE GA
30341-1361
US

V. Phone/Fax

Practice location:
  • Phone: 470-338-3488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: