Provider Demographics
NPI:1881348589
Name:GILMORE, ANGELO (LMSW, LPC)
Entity type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:GILMORE
Suffix:
Gender:M
Credentials:LMSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 VIRGINIA PARK ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2037
Mailing Address - Country:US
Mailing Address - Phone:313-559-0869
Mailing Address - Fax:
Practice Address - Street 1:4512 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3514
Practice Address - Country:US
Practice Address - Phone:248-909-1869
Practice Address - Fax:248-599-7392
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401000319101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional