Provider Demographics
NPI:1245657295
Name:GILMORE, HEATHER (MSW, LLMSW, BCBA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GILMORE
Suffix:
Gender:F
Credentials:MSW, LLMSW, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 S MAGRUDDER RD
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48615-9633
Mailing Address - Country:US
Mailing Address - Phone:989-284-7318
Mailing Address - Fax:
Practice Address - Street 1:308 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1809
Practice Address - Country:US
Practice Address - Phone:989-284-7318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801095830104100000X
MI1-15-21286103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker