Provider Demographics
NPI:1215045414
Name:GILLMORE, ELIZABETH S (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:S
Last Name:GILLMORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 LACEY LN
Mailing Address - Street 2:
Mailing Address - City:TROUTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24175-6568
Mailing Address - Country:US
Mailing Address - Phone:540-977-1102
Mailing Address - Fax:540-344-5343
Practice Address - Street 1:415 S POLLARD ST
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2502
Practice Address - Country:US
Practice Address - Phone:540-977-1102
Practice Address - Fax:540-344-5343
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717000328101Y00000X
VA0701001023101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA023943OtherANTHEM
VA034899OtherVALUE
VA436546OtherANTHEM HEALTHKEEPERS