Provider Demographics
NPI:1073746491
Name:GILLEN, MARTHA RALEIGH (MS)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:RALEIGH
Last Name:GILLEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 OLD OAK WALK
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-8441
Mailing Address - Country:US
Mailing Address - Phone:252-721-0311
Mailing Address - Fax:
Practice Address - Street 1:323 W 2ND ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4801
Practice Address - Country:US
Practice Address - Phone:252-975-3111
Practice Address - Fax:252-975-3035
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC205190101YA0400X
NC8169101YM0800X
NC1386101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health