MEDICARE: DR. LYNNE GILLICK PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	2883	CO

General Provider Information

NPI Number	:	1043420672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYNNE GILLICK PH.D.

Provider Business Mailing Address
First Line	:	5350 TOMAH DR STE 3600
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-6903
Country	:	US
Telephone Number	:	719-201-4245
Fax Number	:

Provider Business Practice Location Address
First Line	:	5350 TOMAH DR
Second Line	:	SUITE 3600
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-6904
Country	:	US
Telephone Number	:	719-201-4245
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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