Provider Demographics
NPI:1114389566
Name:GILMORE, EDWINA (LISW)
Entity Type:Individual
Prefix:
First Name:EDWINA
Middle Name:
Last Name:GILMORE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8904 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-3139
Mailing Address - Country:US
Mailing Address - Phone:513-644-1030
Mailing Address - Fax:513-644-1025
Practice Address - Street 1:8904 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069
Practice Address - Country:US
Practice Address - Phone:513-644-1030
Practice Address - Fax:513-644-1025
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.18009991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0263359Medicaid