Provider Demographics
NPI:1154119253
Name:GILLIS, MYRIAM
Entity type:Individual
Prefix:
First Name:MYRIAM
Middle Name:
Last Name:GILLIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8015 AVENUE K
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4201
Mailing Address - Country:US
Mailing Address - Phone:347-204-8640
Mailing Address - Fax:
Practice Address - Street 1:16 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-1776
Practice Address - Country:US
Practice Address - Phone:917-859-1609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator