Healthcare Provider Details

I. General information

NPI: 1578498614
Provider Name (Legal Business Name): HEATHER GILLENWATERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 US-41
BARNESVILLE GA
30204
US

IV. Provider business mailing address

2116 BIRDIE RD
GRIFFIN GA
30223-8007
US

V. Phone/Fax

Practice location:
  • Phone: 888-963-2228
  • Fax: 706-780-1705
Mailing address:
  • Phone: 888-963-2228
  • Fax: 706-780-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: