Provider Demographics
NPI:1376809780
Name:GILLIS, AGLAED M (LMSW)
Entity Type:Individual
Prefix:
First Name:AGLAED
Middle Name:M
Last Name:GILLIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 73
Mailing Address - Street 2:
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-0073
Mailing Address - Country:US
Mailing Address - Phone:404-626-2048
Mailing Address - Fax:
Practice Address - Street 1:5815 20TH ST
Practice Address - Street 2:BLDG 213 SUITE 211
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5523
Practice Address - Country:US
Practice Address - Phone:703-805-5588
Practice Address - Fax:703-805-1065
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW004742104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker