Provider Demographics
NPI:1922875624
Name:GILLISSIE, LAURA LEIGH (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEIGH
Last Name:GILLISSIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11530 HIGHWAY 49 STE E
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3089
Mailing Address - Country:US
Mailing Address - Phone:228-707-2007
Mailing Address - Fax:
Practice Address - Street 1:11530 HIGHWAY 49 STE E
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3089
Practice Address - Country:US
Practice Address - Phone:228-707-2007
Practice Address - Fax:228-707-4119
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC104491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical