Provider Demographics
NPI:1083410518
Name:WILLMORE, GAIL ANNE (LAC)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:ANNE
Last Name:WILLMORE
Suffix:
Gender:
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 N CENTRAL AVE STE 707
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1024
Mailing Address - Country:US
Mailing Address - Phone:602-849-7174
Mailing Address - Fax:
Practice Address - Street 1:2828 N CENTRAL AVE STE 707
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1024
Practice Address - Country:US
Practice Address - Phone:602-849-7174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21049101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health