Provider Demographics
NPI:1467967513
Name:MARTIN, GILLIE WISDOM (RBT)
Entity Type:Individual
Prefix:MISS
First Name:GILLIE
Middle Name:WISDOM
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3243 ELECTRIC RD.
Mailing Address - Street 2:BUILDING E SUITE 1B
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018
Mailing Address - Country:US
Mailing Address - Phone:540-404-1189
Mailing Address - Fax:540-904-0096
Practice Address - Street 1:3243 ELECTRIC RD BLDG E
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-6440
Practice Address - Country:US
Practice Address - Phone:540-404-1189
Practice Address - Fax:540-904-0096
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-17-31327106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician