Provider Demographics
NPI:1083374201
Name:GILLES, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GILLES
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 1:314 S OCEAN AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-4957
Mailing Address - Country:US
Mailing Address - Phone:516-448-6518
Mailing Address - Fax:
Practice Address - Street 1:2 ROOSEVELT AVE STE 300
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3064
Practice Address - Country:US
Practice Address - Phone:516-758-4119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11-3449823Medicaid