Provider Demographics
NPI:1033728613
Name:GILLIS, SIERRA
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:
Last Name:GILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45773 BRYN MAWR RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5431
Mailing Address - Country:US
Mailing Address - Phone:734-626-2925
Mailing Address - Fax:
Practice Address - Street 1:15000 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1973
Practice Address - Country:US
Practice Address - Phone:313-423-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000029103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist