Healthcare Provider Details

I. General information

NPI: 1174764989
Provider Name (Legal Business Name): LAURA GILLAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 SW GILSON ST
MCMINNVILLE OR
97128-6913
US

IV. Provider business mailing address

717 SW GILSON ST
MCMINNVILLE OR
97128-6913
US

V. Phone/Fax

Practice location:
  • Phone: 503-472-1301
  • Fax: 503-472-3199
Mailing address:
  • Phone: 503-472-1301
  • Fax: 503-472-3199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberL3682
License Number StateOR

VIII. Authorized Official

Name: LAURA GILLAS
Title or Position: SOLE MBR
Credential: LCSW
Phone: 503-472-1301