Provider Demographics
NPI:1760658496
Name:GILLETTE, MARTIN G (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:G
Last Name:GILLETTE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2577 NE COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7638
Mailing Address - Country:US
Mailing Address - Phone:541-322-7595
Mailing Address - Fax:541-322-7566
Practice Address - Street 1:2577 NE COURTNEY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7638
Practice Address - Country:US
Practice Address - Phone:541-322-7595
Practice Address - Fax:541-322-7566
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical