Provider Demographics
NPI:1013930403
Name:FORTUNE-GILPIN, MILDRED ELIZABETH (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:ELIZABETH
Last Name:FORTUNE-GILPIN
Suffix:
Gender:F
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 1:1150 GRAHAM RD STE 102
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-8077
Mailing Address - Country:US
Mailing Address - Phone:314-206-3900
Mailing Address - Fax:314-206-3992
Practice Address - Street 1:1150 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8077
Practice Address - Country:US
Practice Address - Phone:314-206-3900
Practice Address - Fax:314-206-3992
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020149921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical