Provider Demographics
NPI:1811200108
Name:GILL, GREG GLENN JR
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:GLENN
Last Name:GILL
Suffix:JR
Gender:M
Credentials:
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 323
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97004-0323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25915 S FALLSVIEW RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OR
Practice Address - Zip Code:97004-9638
Practice Address - Country:US
Practice Address - Phone:503-550-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)