Provider Demographics
NPI:1609052646
Name:GILLIS, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GILLIS
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 1:3250 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 228
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-2900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3250 W BIG BEAVER RD
Practice Address - Street 2:SUITE 228
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-2900
Practice Address - Country:US
Practice Address - Phone:248-792-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-19
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010010872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer