Provider Demographics
NPI:1770319030
Name:GAILLARD, LORETTA
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:GAILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3065 DWYER ROAD
Mailing Address - Street 2:
Mailing Address - City:SUMPTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150
Mailing Address - Country:US
Mailing Address - Phone:757-713-2422
Mailing Address - Fax:
Practice Address - Street 1:15 CALDWELL STREET
Practice Address - Street 2:
Practice Address - City:SUMPTER
Practice Address - State:SC
Practice Address - Zip Code:29150
Practice Address - Country:US
Practice Address - Phone:803-774-7312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLPC.8679PC101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty