Provider Demographics
NPI:1407959034
Name:GILLIES, MARY C (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:C
Last Name:GILLIES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 INDIA STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101
Mailing Address - Country:US
Mailing Address - Phone:207-773-0207
Mailing Address - Fax:207-773-6207
Practice Address - Street 1:95 INDIA STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-773-0207
Practice Address - Fax:207-773-6207
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC50431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GIMM6148Medicare UPIN
MEMM6148Medicare ID - Type Unspecified