Provider Demographics
NPI:1740491356
Name:FIRESTONE-GILLIS, CAROLE SUSAN (MA, MFT)
Entity type:Individual
Prefix:
First Name:CAROLE
Middle Name:SUSAN
Last Name:FIRESTONE-GILLIS
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 CHINN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4338
Mailing Address - Country:US
Mailing Address - Phone:707-528-1398
Mailing Address - Fax:
Practice Address - Street 1:411 CHINN ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4338
Practice Address - Country:US
Practice Address - Phone:707-528-1398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT13252106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist