Provider Demographics
NPI:1548485642
Name:GILLIS, MARY VASTE (MFT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:VASTE
Last Name:GILLIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 LIBERTY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2320
Mailing Address - Country:US
Mailing Address - Phone:707-765-9021
Mailing Address - Fax:
Practice Address - Street 1:115 LIBERTY ST STE 1
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2320
Practice Address - Country:US
Practice Address - Phone:707-765-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT29225106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist