Provider Demographics
NPI:1255942876
Name:CU, MARK GILLIES
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GILLIES
Last Name:CU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 211TH ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1435
Mailing Address - Country:US
Mailing Address - Phone:310-283-0438
Mailing Address - Fax:
Practice Address - Street 1:2131 DAVIDSONVILLE RD
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1632
Practice Address - Country:US
Practice Address - Phone:410-721-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02887224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant