Provider Demographics
NPI:1386837052
Name:GILLILAND, PATRICK EDWARD (LMFT)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:EDWARD
Last Name:GILLILAND
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 STONEY POINT RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7861
Mailing Address - Country:US
Mailing Address - Phone:602-463-5673
Mailing Address - Fax:
Practice Address - Street 1:9635 VENTANA WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-8620
Practice Address - Country:US
Practice Address - Phone:678-366-8862
Practice Address - Fax:678-739-0119
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GAMFT001143106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12140978OtherCAQH