Provider Demographics
NPI:1720206543
Name:GILLIS, MIGGS W (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIGGS
Middle Name:W
Last Name:GILLIS
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 1:139 LAKESHORE DR S
Mailing Address - Street 2:
Mailing Address - City:LAKE QUIVIRA
Mailing Address - State:KS
Mailing Address - Zip Code:66217-8516
Mailing Address - Country:US
Mailing Address - Phone:913-962-1293
Mailing Address - Fax:
Practice Address - Street 1:7611 STATE LINE RD
Practice Address - Street 2:#135
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-6801
Practice Address - Country:US
Practice Address - Phone:816-822-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01587103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist