Provider Demographics
NPI:1962751677
Name:GILLIAN, TRICIA VICK (MASTERS, SSP)
Entity type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:VICK
Last Name:GILLIAN
Suffix:
Gender:F
Credentials:MASTERS, SSP
Other - Prefix:MISS
Other - First Name:TRICIA
Other - Middle Name:LYNN
Other - Last Name:VICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASTERS, SSP
Mailing Address - Street 1:811 BRADBERRY LN
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-5104
Mailing Address - Country:US
Mailing Address - Phone:252-904-4426
Mailing Address - Fax:
Practice Address - Street 1:811 BRADBERRY LN
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5104
Practice Address - Country:US
Practice Address - Phone:252-904-4426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4328103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist