Provider Demographics
NPI:1679763726
Name:GILLISON, T'WANA LUCRETIA (RS8623)
Entity type:Individual
Prefix:MRS
First Name:T'WANA
Middle Name:LUCRETIA
Last Name:GILLISON
Suffix:
Gender:F
Credentials:RS8623
Other - Prefix:MS
Other - First Name:T'WANA
Other - Middle Name:LUCRETIA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1076 SANTO ANTONIO DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-8103
Mailing Address - Country:US
Mailing Address - Phone:909-433-9824
Mailing Address - Fax:909-433-9527
Practice Address - Street 1:1076 SANTO ANTONIO DR
Practice Address - Street 2:SUITE B
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-8103
Practice Address - Country:US
Practice Address - Phone:909-433-9824
Practice Address - Fax:909-433-9527
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)