Provider Demographics
NPI:1972817906
Name:GREMILLION, MARY JAN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JAN
Last Name:GREMILLION
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 1:5151 EVERETT LN
Mailing Address - Street 2:# A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3693
Mailing Address - Country:US
Mailing Address - Phone:225-505-5745
Mailing Address - Fax:
Practice Address - Street 1:1900 S ACADIAN THRUWAY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-1665
Practice Address - Country:US
Practice Address - Phone:225-336-8708
Practice Address - Fax:225-336-8703
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6601104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker