Provider Demographics
NPI:1619634425
Name:MILLIE GAITAN COUNSELING PLLC
Entity Type:Organization
Organization Name:MILLIE GAITAN COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:MILDRED A
Authorized Official - Middle Name:GAITAN
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-421-1024
Mailing Address - Street 1:160 MAIN AVE N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6101
Mailing Address - Country:US
Mailing Address - Phone:208-733-3024
Mailing Address - Fax:208-733-0929
Practice Address - Street 1:160 MAIN AVE N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6101
Practice Address - Country:US
Practice Address - Phone:208-733-3024
Practice Address - Fax:208-733-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0056-0347063Medicaid