Provider Demographics
NPI:1770968414
Name:GILMORE, SAMANTHA ADELLE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ADELLE
Last Name:GILMORE
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 1:815 FLACK AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-2722
Mailing Address - Country:US
Mailing Address - Phone:308-762-2723
Mailing Address - Fax:308-217-4277
Practice Address - Street 1:815 FLACK AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-2722
Practice Address - Country:US
Practice Address - Phone:308-762-2723
Practice Address - Fax:308-217-4277
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1338101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)