Provider Demographics
NPI:1891186623
Name:GILLOGLY, MARK (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GILLOGLY
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 WEST PORTAL AVENUE
Mailing Address - Street 2:BOX 295
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-1423
Mailing Address - Country:US
Mailing Address - Phone:415-418-0630
Mailing Address - Fax:
Practice Address - Street 1:236 WEST PORTAL AVENUE
Practice Address - Street 2:BOX 295
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-1423
Practice Address - Country:US
Practice Address - Phone:415-418-0630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA164001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16400OtherBOARD OF BEHAVIORAL EXAMINERS, STATE OF CA DEPARTMENT OF CONSUMER AFFAIRS