Provider Demographics
NPI:1417078866
Name:GILMORE, BETTY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BETTY
Middle Name:
Last Name:GILMORE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 CASCADE RD SE
Mailing Address - Street 2:BUILDING 1 SUITE 6
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3666
Mailing Address - Country:US
Mailing Address - Phone:616-644-4635
Mailing Address - Fax:
Practice Address - Street 1:4519 CASCADE RD SE
Practice Address - Street 2:BUILDING 1 SUITE 6
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3666
Practice Address - Country:US
Practice Address - Phone:616-644-4635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011308103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist