Provider Demographics
NPI:1679684575
Name:GILMORE, MARTHA LOUISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:LOUISE
Last Name:GILMORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 OAK AVE
Mailing Address - Street 2:STE B
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1000
Mailing Address - Country:US
Mailing Address - Phone:530-757-6861
Mailing Address - Fax:530-753-0636
Practice Address - Street 1:1621 OAK AVE
Practice Address - Street 2:STE B
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-1000
Practice Address - Country:US
Practice Address - Phone:530-757-6861
Practice Address - Fax:530-753-0636
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10451103TC0700X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy