Provider Demographics
NPI:1124416953
Name:GILLEN, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
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 1:3600 EUBANK BLVD NE
Mailing Address - Street 2:UNIT 9B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-4846
Mailing Address - Country:US
Mailing Address - Phone:505-620-3976
Mailing Address - Fax:505-923-4850
Practice Address - Street 1:3600 EUBANK BLVD NE
Practice Address - Street 2:UNIT 9B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-4846
Practice Address - Country:US
Practice Address - Phone:505-620-3976
Practice Address - Fax:505-923-4850
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-01
Last Update Date:2015-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1587224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant