Provider Demographics
NPI:1245630854
Name:GILLIS, MARY MEREDITH (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MEREDITH
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-9437
Mailing Address - Fax:
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-384-9437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4667103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ48648AMedicare UPIN