Provider Demographics
NPI:1790830719
Name:GILLIS, MARSHA T (PHD)
Entity Type:Individual
Prefix:MRS
First Name:MARSHA
Middle Name:T
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:PO BOX 629
Mailing Address - Street 2:6512 MAIN STREET
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061
Mailing Address - Country:US
Mailing Address - Phone:804-693-9933
Mailing Address - Fax:804-693-4545
Practice Address - Street 1:6512 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061
Practice Address - Country:US
Practice Address - Phone:804-693-9933
Practice Address - Fax:804-693-4545
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002924103TC0700X
MA6750103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical