Provider Demographics
NPI:1376795112
Name:GILL-MANVILLE, STEPHANIE (LPC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GILL-MANVILLE
Suffix:
Gender:F
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:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-0390
Mailing Address - Country:US
Mailing Address - Phone:860-271-4700
Mailing Address - Fax:860-271-4797
Practice Address - Street 1:21 MONTAUK AVENE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6397
Practice Address - Country:US
Practice Address - Phone:860-271-4700
Practice Address - Fax:860-271-4797
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001752101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004253027Medicaid