Provider Demographics
NPI:1013552496
Name:GILLEN, BRANDI LOUISE
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:LOUISE
Last Name:GILLEN
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 1:9992 AKINS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-4547
Mailing Address - Country:US
Mailing Address - Phone:321-508-9322
Mailing Address - Fax:
Practice Address - Street 1:9992 AKINS RD
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-4547
Practice Address - Country:US
Practice Address - Phone:321-508-9322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-09
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist