Provider Demographics
NPI:1508090812
Name:GILL, STEPHEN TODD (PHD DR)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:TODD
Last Name:GILL
Suffix:
Gender:M
Credentials:PHD DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3123 GUY CIR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5334
Mailing Address - Country:US
Mailing Address - Phone:910-494-1253
Mailing Address - Fax:
Practice Address - Street 1:1218 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-6845
Practice Address - Country:US
Practice Address - Phone:910-893-6021
Practice Address - Fax:910-893-6051
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC#5197101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1003086752Medicaid