Provider Demographics
NPI:1194961961
Name:GILLERAN, LUKE J (MA, NCC, LACD, CCDP)
Entity type:Individual
Prefix:MR
First Name:LUKE
Middle Name:J
Last Name:GILLERAN
Suffix:
Gender:M
Credentials:MA, NCC, LACD, CCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 UNQUOWA RD
Mailing Address - Street 2:APT #126
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5057
Mailing Address - Country:US
Mailing Address - Phone:203-520-3465
Mailing Address - Fax:
Practice Address - Street 1:1 LONG WHARF DR
Practice Address - Street 2:SUITE 321
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:203-781-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000857101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004041000Medicaid
CT008003745Medicaid
CT008038039Medicaid