Provider Demographics
NPI:1821370800
Name:GILLIGAN, COLLEEN GRACE
Entity Type:Individual
Prefix:MISS
First Name:COLLEEN
Middle Name:GRACE
Last Name:GILLIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4625
Mailing Address - Country:US
Mailing Address - Phone:631-853-7300
Mailing Address - Fax:631-853-7301
Practice Address - Street 1:2171 JERICHO TPKE STE LL3
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2900
Practice Address - Country:US
Practice Address - Phone:631-603-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY823156527OtherPSCHOTHERAPY/DIRECT CARE