Provider Demographics
NPI:1801633540
Name:GILLIGAN, ADDISON
Entity type:Individual
Prefix:
First Name:ADDISON
Middle Name:
Last Name:GILLIGAN
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 1:1510 ATAMI CT
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6845
Mailing Address - Country:US
Mailing Address - Phone:352-727-1290
Mailing Address - Fax:
Practice Address - Street 1:13424 FORT KING RD
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5214
Practice Address - Country:US
Practice Address - Phone:352-437-3559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-360152106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician