Provider Demographics
NPI:1043448251
Name:GILLEN, PETER ANDREW (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:ANDREW
Last Name:GILLEN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-2320
Mailing Address - Country:US
Mailing Address - Phone:516-454-1121
Mailing Address - Fax:
Practice Address - Street 1:11 SPENCER ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2320
Practice Address - Country:US
Practice Address - Phone:516-454-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011327-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist