Provider Demographics
NPI:1801964382
Name:GILLETT, NEAL ALLEN (MA)
Entity type:Individual
Prefix:
First Name:NEAL
Middle Name:ALLEN
Last Name:GILLETT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14024 ROYAL CT
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-3928
Mailing Address - Country:US
Mailing Address - Phone:952-933-4085
Mailing Address - Fax:952-417-2146
Practice Address - Street 1:10520 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55305-1511
Practice Address - Country:US
Practice Address - Phone:612-220-1151
Practice Address - Fax:952-681-2568
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2348103T00000X
MN80581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4H5581GI 4H557GI LPOtherBLUE CROSS BLUE SHIELD
MN673552500OtherMEDICAL ASSISTANCE