Provider Demographics
NPI:1710150081
Name:GAILLARD, AUDREY FIDLER (LPC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:FIDLER
Last Name:GAILLARD
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 1:2 HILLSBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3325
Mailing Address - Country:US
Mailing Address - Phone:864-247-8836
Mailing Address - Fax:
Practice Address - Street 1:2 HILLSBOROUGH DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3325
Practice Address - Country:US
Practice Address - Phone:864-247-8836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5475101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health