MEDICARE: MS. IVY GILMORE

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	1041C0700X	Clinical Social Worker	19419	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19419	OTHER	MD	SOCIAL WORK LICENSE
2	50078633	OTHER	DC	SOCIAL WORK LICENSE

General Provider Information

NPI Number	:	1114596202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. IVY GILMORE

Provider Business Mailing Address
First Line	:	2839 31ST PL NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20018-1603
Country	:	US
Telephone Number	:	202-751-8579
Fax Number	:

Provider Business Practice Location Address
First Line	:	2839 31ST PL NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20018-1603
Country	:	US
Telephone Number	:	202-751-8579
Fax Number	:

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

Provider Enumeration Date	:	06/22/2021
Last Update Date	:	06/22/2021

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