Provider Demographics
NPI:1720360779
Name:GILLILAND, MARK (MDIV)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GILLILAND
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:786 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3710
Mailing Address - Country:US
Mailing Address - Phone:406-210-3388
Mailing Address - Fax:
Practice Address - Street 1:786 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3710
Practice Address - Country:US
Practice Address - Phone:406-210-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNONE101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral