Healthcare Provider Details

I. General information

NPI: 1144833385
Provider Name (Legal Business Name): GILLIAN SMALL LAC, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2020
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 VALLEY HEALTH PLZ
PARAMUS NJ
07652-3607
US

IV. Provider business mailing address

610 VALLEY HEALTH PLZ
PARAMUS NJ
07652-3607
US

V. Phone/Fax

Practice location:
  • Phone: 201-693-8448
  • Fax:
Mailing address:
  • Phone: 201-693-8448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37CA00156700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAC-GTL-20-01543
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: