Provider Demographics
NPI:1164172664
Name:GILES, DAVID RUSSELL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RUSSELL
Last Name:GILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15303 S 94TH AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3825
Mailing Address - Country:US
Mailing Address - Phone:888-428-7890
Mailing Address - Fax:877-428-7891
Practice Address - Street 1:15303 S 94TH AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3825
Practice Address - Country:US
Practice Address - Phone:888-428-7890
Practice Address - Fax:877-428-7891
Is Sole Proprietor?:No
Enumeration Date:2022-03-27
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105906104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker