Provider Demographics
NPI:1982364956
Name:GILLMAN, TINA MARIE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:GILLMAN
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:PO BOX 408
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-0408
Mailing Address - Country:US
Mailing Address - Phone:616-214-9306
Mailing Address - Fax:
Practice Address - Street 1:1236 E BERNIE CT
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-9377
Practice Address - Country:US
Practice Address - Phone:616-214-9306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst