Provider Demographics
NPI:1083017073
Name:GILLEN, GILFORD LEE JR (LPC)
Entity Type:Individual
Prefix:
First Name:GILFORD
Middle Name:LEE
Last Name:GILLEN
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SOUTHFIELD RD.
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106
Mailing Address - Country:US
Mailing Address - Phone:318-869-1632
Mailing Address - Fax:318-869-1633
Practice Address - Street 1:707 SOUTHFIELD RD.
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-869-1632
Practice Address - Fax:318-869-1633
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5077101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional