Healthcare Provider Details

I. General information

NPI: 1164893699
Provider Name (Legal Business Name): RAYMOND MICHAEL GILLETT LMSW, LAC, MDIV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7308 W HALE ST
WICHITA KS
67212-3141
US

IV. Provider business mailing address

7308 W HALE ST
WICHITA KS
67212-3141
US

V. Phone/Fax

Practice location:
  • Phone: 860-428-9547
  • Fax:
Mailing address:
  • Phone: 860-428-9547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number4877
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number001
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4877
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4877
License Number StateKS
# 6
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4877
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: