Provider Demographics
NPI:1689655425
Name:GILLAN, GARTH JACKSON (DMIN)
Entity Type:Individual
Prefix:DR
First Name:GARTH
Middle Name:JACKSON
Last Name:GILLAN
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W BEAVER AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-4836
Mailing Address - Country:US
Mailing Address - Phone:814-234-2279
Mailing Address - Fax:814-422-0778
Practice Address - Street 1:108 W BEAVER AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-4836
Practice Address - Country:US
Practice Address - Phone:814-234-2279
Practice Address - Fax:814-422-0778
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC002317101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional