MEDICARE: MARTHA M 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	103TC0700X	Clinical Psychologist	0810003445	VA

General Provider Information

NPI Number	:	1871657080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA M GILLIS PH.D.

Provider Business Mailing Address
First Line	:	11166 FAIRFAX BLVD
Second Line	:	SUITE 203
City	:	FAIRFAX
State	:	VA
Zip	:	22030-5017
Country	:	US
Telephone Number	:	703-819-8445
Fax Number	:

Provider Business Practice Location Address
First Line	:	11166 FAIRFAX BLVD
Second Line	:	SUITE 203
City	:	FAIRFAX
State	:	VA
Zip	:	22030-5017
Country	:	US
Telephone Number	:	703-819-8445
Fax Number	:

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

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	11/29/2011

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