Provider Demographics
NPI:1225629272
Name:GILLELAND, KRISTINA (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:GILLELAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 KING AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2965
Mailing Address - Country:US
Mailing Address - Phone:770-540-3674
Mailing Address - Fax:
Practice Address - Street 1:700 OGLETHORPE AVE STE C7
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2221
Practice Address - Country:US
Practice Address - Phone:706-425-9445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0068141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical