Provider Demographics
NPI:1699223800
Name:GILLIS, LAURA (LPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GILLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 WATER TOWER DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:WI
Mailing Address - Zip Code:53559-9042
Mailing Address - Country:US
Mailing Address - Phone:608-712-0217
Mailing Address - Fax:
Practice Address - Street 1:624 WATER TOWER DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:WI
Practice Address - Zip Code:53559-9042
Practice Address - Country:US
Practice Address - Phone:608-712-0217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5896101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional