Provider Demographics
NPI:1245607738
Name:GILMORE, VIVIAN ILENE
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:ILENE
Last Name:GILMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:ILENE
Other - Last Name:GILMORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1230 SAN TOMAS AQUINO RD APT 221
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-3336
Mailing Address - Country:US
Mailing Address - Phone:408-888-1185
Mailing Address - Fax:
Practice Address - Street 1:1671 THE ALAMEDA STE 306
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2222
Practice Address - Country:US
Practice Address - Phone:669-236-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132460106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist