Provider Demographics
NPI:1861865396
Name:GILLARD, CHARLES WARREN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WARREN
Last Name:GILLARD
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-9433
Mailing Address - Country:US
Mailing Address - Phone:575-571-0535
Mailing Address - Fax:
Practice Address - Street 1:4835 EMERALD ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-9433
Practice Address - Country:US
Practice Address - Phone:575-571-0535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-086111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical