Provider Demographics
NPI:1639398258
Name:GILL, MARY JO (LMFT)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:GILL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT-I
Mailing Address - Street 1:1810 E SAHARA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-3707
Mailing Address - Country:US
Mailing Address - Phone:702-706-7855
Mailing Address - Fax:702-543-5109
Practice Address - Street 1:1810 E SAHARA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3707
Practice Address - Country:US
Practice Address - Phone:702-706-7855
Practice Address - Fax:702-543-5109
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI0795106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100511740Medicaid