Provider Demographics
NPI:1922513894
Name:GILLEN, MICAH A (MS, LPC)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:A
Last Name:GILLEN
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 S WINTER ST STE 1022
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-3876
Mailing Address - Country:US
Mailing Address - Phone:517-263-8905
Mailing Address - Fax:
Practice Address - Street 1:1040 S WINTER ST STE 1022
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-3876
Practice Address - Country:US
Practice Address - Phone:517-263-8905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017042234101YP2500X
MI6401223314101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2017042234OtherPLPC LICENSE
MO490054503Medicaid