MEDICARE: DR. HOWARD MARK GILLIS 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	103T00000X	Psychologist	PSY6977	CA

General Provider Information

NPI Number	:	1639331531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HOWARD MARK GILLIS PH.D.

Provider Business Mailing Address
First Line	:	1736 DIVISADERO ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94115-3012
Country	:	US
Telephone Number	:	415-346-2234
Fax Number	:

Provider Business Practice Location Address
First Line	:	1736 DIVISADERO ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94115-3012
Country	:	US
Telephone Number	:	415-346-2234
Fax Number	:

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

Provider Enumeration Date	:	07/01/2008
Last Update Date	:	07/01/2008

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