Provider Demographics
NPI:1477291953
Name:GILES, ETHEL ANDREA
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:ANDREA
Last Name:GILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2804
Mailing Address - Country:US
Mailing Address - Phone:651-263-0726
Mailing Address - Fax:
Practice Address - Street 1:936 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2804
Practice Address - Country:US
Practice Address - Phone:651-263-0726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306329101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)