Healthcare Provider Details

I. General information

NPI: 1023642253
Provider Name (Legal Business Name): JUSTIN SEAN GILLIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MILL ST
BELMONT MA
02478-1064
US

IV. Provider business mailing address

115 MILL ST
BELMONT MA
02478-1064
US

V. Phone/Fax

Practice location:
  • Phone: 617-855-2459
  • Fax: 617-855-3470
Mailing address:
  • Phone: 617-855-2459
  • Fax: 617-855-3470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN GILLIS
Title or Position: OWNER
Credential: LICSW
Phone: 774-273-0594