Provider Demographics
NPI:1134310790
Name:GILLMAN, STEPHEN I (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:I
Last Name:GILLMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SCHENCK AVE
Mailing Address - Street 2:APT 1CD
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3640
Mailing Address - Country:US
Mailing Address - Phone:631-490-5789
Mailing Address - Fax:
Practice Address - Street 1:23 SCHENCK AVE
Practice Address - Street 2:APT 1CD
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3640
Practice Address - Country:US
Practice Address - Phone:631-490-5789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003667103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical