MEDICARE: DETRA S GILLIANS

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1619644754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DETRA S GILLIANS

Provider Business Mailing Address
First Line	:	3174 RIVERDALE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-3839
Country	:	US
Telephone Number	:	347-450-6164
Fax Number	:

Provider Business Practice Location Address
First Line	:	3174 RIVERDALE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-3839
Country	:	US
Telephone Number	:	347-450-6164
Fax Number	:

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

Provider Enumeration Date	:	08/26/2021
Last Update Date	:	10/18/2021

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Directions to “ DETRA S GILLIANS ” Practice Location

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