Provider Demographics
NPI:1912604166
Name:GILLIS, DANI MADISON I (SUDP-T)
Entity type:Individual
Prefix:
First Name:DANI
Middle Name:MADISON
Last Name:GILLIS
Suffix:I
Gender:F
Credentials:SUDP-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11704 AMBAUM BLVD SW
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98146-4604
Mailing Address - Country:US
Mailing Address - Phone:206-233-3644
Mailing Address - Fax:
Practice Address - Street 1:3805 108TH AVE NE STE 102
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-7613
Practice Address - Country:US
Practice Address - Phone:425-242-1713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WA61414893101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor