Provider Demographics
NPI:1821003518
Name:GILLEN, MARIA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:GILLEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 SAINT CYR AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-5104
Mailing Address - Country:US
Mailing Address - Phone:505-766-9773
Mailing Address - Fax:
Practice Address - Street 1:1700 PRINCETON DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3114
Practice Address - Country:US
Practice Address - Phone:505-243-3161
Practice Address - Fax:505-243-3161
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3040235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40886255Medicaid