Provider Demographics
NPI:1427667328
Name:GILL, GRANT JUDSON
Entity type:Individual
Prefix:MR
First Name:GRANT
Middle Name:JUDSON
Last Name:GILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 LACLAIR ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2988
Mailing Address - Country:US
Mailing Address - Phone:541-266-6700
Mailing Address - Fax:
Practice Address - Street 1:1817 16TH ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-2629
Practice Address - Country:US
Practice Address - Phone:541-297-6230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCMK7119BMedicaid