Provider Demographics
NPI:1275023210
Name:GILLEMS, PATRICE J
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:J
Last Name:GILLEMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 S MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-2925
Mailing Address - Country:US
Mailing Address - Phone:330-318-3436
Mailing Address - Fax:
Practice Address - Street 1:238 S MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-2925
Practice Address - Country:US
Practice Address - Phone:330-318-3436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid