Provider Demographics
NPI:1467791145
Name:GILMORE, ERIC DOUGLAS (LCSW, LAC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DOUGLAS
Last Name:GILMORE
Suffix:
Gender:M
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 N LAST CHANCE GULCH
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-3352
Mailing Address - Country:US
Mailing Address - Phone:406-422-4933
Mailing Address - Fax:800-309-2162
Practice Address - Street 1:833 N LAST CHANCE GULCH
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-3352
Practice Address - Country:US
Practice Address - Phone:406-422-4933
Practice Address - Fax:800-309-2162
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1258101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
81-2353711OtherFEDERAL TAX ID
MTBBH-LAC-LICOtherLICENSE
MTBBH-LAC-LIC-1258OtherSTATE LICENSE