Provider Demographics
NPI:1477925121
Name:GILLEN, MICHAEL JOSEPH (PHD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:GILLEN
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 1:21425 SPRING STREET
Mailing Address - Street 2:UNION GROVE VA CLINIC
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182
Mailing Address - Country:US
Mailing Address - Phone:262-878-7020
Mailing Address - Fax:
Practice Address - Street 1:21425 SPRING STREET
Practice Address - Street 2:UNION GROVE VA CLINIC
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182
Practice Address - Country:US
Practice Address - Phone:262-878-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3313-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical