Healthcare Provider Details

I. General information

NPI: 1942624580
Provider Name (Legal Business Name): PATRICK EDWARD GILLILAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9635 VENTANA WAY SUITE 101
JOHNS CREEK GA
30022-8620
US

IV. Provider business mailing address

9635 VENTANA WAY SUITE 101
JOHNS CREEK GA
30022-8620
US

V. Phone/Fax

Practice location:
  • Phone: 678-366-8862
  • Fax: 678-739-0119
Mailing address:
  • Phone: 678-366-8862
  • Fax: 678-739-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT001143
License Number StateGA

VIII. Authorized Official

Name: MR. PATRICK EDWARD GILLILAND
Title or Position: MARRIAGE AND FAMILY THERAPIST
Credential: LMFT
Phone: 602-463-5673