Provider Demographics
NPI:1154639763
Name:GILLIS, TIMOTHY (LPC, LPCS, MAC, CDCI)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:GILLIS
Suffix:
Gender:M
Credentials:LPC, LPCS, MAC, CDCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1692
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-1692
Mailing Address - Country:US
Mailing Address - Phone:907-398-0524
Mailing Address - Fax:888-678-2961
Practice Address - Street 1:110 N WILLOW ST
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7701
Practice Address - Country:US
Practice Address - Phone:907-398-0524
Practice Address - Fax:888-678-2961
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK624101YP2500X
AK508906101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)