Provider Demographics
NPI:1154050581
Name:GILL, DEJA DESIRAE
Entity Type:Individual
Prefix:
First Name:DEJA
Middle Name:DESIRAE
Last Name:GILL
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 1:14100 SAN PEDRO AVE STE 412
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2009
Mailing Address - Country:US
Mailing Address - Phone:210-281-8669
Mailing Address - Fax:210-314-5044
Practice Address - Street 1:24200 IH 10 W STE 109
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-1150
Practice Address - Country:US
Practice Address - Phone:210-263-9443
Practice Address - Fax:726-999-2625
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TXRBT-22-225351106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician