Provider Demographics
NPI:1386822377
Name:GILLIS, DOMINIQUE A (MFT)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:A
Last Name:GILLIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:A
Other - Last Name:JEFFERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-5200
Mailing Address - Fax:
Practice Address - Street 1:300 UCLA MEDICAL PLAZA
Practice Address - Street 2:SUITE 2200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8346
Practice Address - Country:US
Practice Address - Phone:323-271-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-01
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53674106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist