Provider Demographics
NPI:1871657080
Name:GILLIS, MARTHA M (PHD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:M
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 1:11166 FAIRFAX BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5017
Mailing Address - Country:US
Mailing Address - Phone:703-819-8445
Mailing Address - Fax:
Practice Address - Street 1:11166 FAIRFAX BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5017
Practice Address - Country:US
Practice Address - Phone:703-819-8445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003445103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical