Provider Demographics
NPI:1922071307
Name:GILL, STEPHEN (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:GILL
Suffix:
Gender:M
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 4509
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86340-4509
Mailing Address - Country:US
Mailing Address - Phone:928-282-5982
Mailing Address - Fax:928-282-5983
Practice Address - Street 1:70 N PAYNE PL
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-4536
Practice Address - Country:US
Practice Address - Phone:928-282-5982
Practice Address - Fax:928-282-5983
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11426103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R27425Medicare UPIN