Provider Demographics
NPI:1083805451
Name:GILLIS, AUDRA N (MSW)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:N
Last Name:GILLIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16314 BOSWELL PL
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3286
Mailing Address - Country:US
Mailing Address - Phone:301-442-1990
Mailing Address - Fax:301-627-1806
Practice Address - Street 1:1701 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721-2213
Practice Address - Country:US
Practice Address - Phone:301-442-1990
Practice Address - Fax:301-627-1806
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD130711041C0700X
DCLC500781831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical