Provider Demographics
NPI:1487102653
Name:GILLES, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GILLES
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 1:15055 NW 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-3365
Mailing Address - Country:US
Mailing Address - Phone:786-466-2800
Mailing Address - Fax:
Practice Address - Street 1:15055 NW 27TH AVE
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-3365
Practice Address - Country:US
Practice Address - Phone:786-466-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health