Provider Demographics
NPI:1518035005
Name:GILLOCK, KAREN LEE (PHD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:LEE
Last Name:GILLOCK
Suffix:
Gender:F
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:PO BOX 769
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-0769
Mailing Address - Country:US
Mailing Address - Phone:603-448-3588
Mailing Address - Fax:603-448-3583
Practice Address - Street 1:115 ETNA RD
Practice Address - Street 2:BUILDING 1, SUITE 2
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1429
Practice Address - Country:US
Practice Address - Phone:603-448-3588
Practice Address - Fax:603-448-3583
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH943103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008149OtherMEDICAID
NH30421560Medicaid
NHRE6367Medicare ID - Type Unspecified
NH30421560Medicaid