Provider Demographics
NPI:1053136283
Name:GILLIS, RAQUEL TASHIANA
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:TASHIANA
Last Name:GILLIS
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 1:4033 DOVER DR E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-4082
Mailing Address - Country:US
Mailing Address - Phone:941-524-1361
Mailing Address - Fax:
Practice Address - Street 1:4033 DOVER DR E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-4082
Practice Address - Country:US
Practice Address - Phone:941-524-1361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB921639106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician