Provider Demographics
NPI:1104830785
Name:GILLEN, MARK CLIFFORD (LPC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CLIFFORD
Last Name:GILLEN
Suffix:
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 1:257 N PIETY ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011-5056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:257 N PIETY ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011-5056
Practice Address - Country:US
Practice Address - Phone:715-425-3890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI913-125101YP2500X
WI3992-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical