Provider Demographics
NPI:1790538320
Name:GILLMORE, HEIDI (LMHCA)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:GILLMORE
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 179TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-1953
Mailing Address - Country:US
Mailing Address - Phone:319-480-3454
Mailing Address - Fax:
Practice Address - Street 1:5620 112TH ST E STE 215
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3206
Practice Address - Country:US
Practice Address - Phone:253-444-7176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61346607101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health