Provider Demographics
NPI:1215587589
Name:GILMORE, SCOTTY MICHAEL (LPC)
Entity Type:Individual
Prefix:MR
First Name:SCOTTY
Middle Name:MICHAEL
Last Name:GILMORE
Suffix:
Gender:M
Credentials:LPC
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 11632
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-0632
Mailing Address - Country:US
Mailing Address - Phone:817-925-3065
Mailing Address - Fax:
Practice Address - Street 1:110 SW THOMAS ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-3818
Practice Address - Country:US
Practice Address - Phone:817-862-7906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78287101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health