Provider Demographics
NPI:1306244710
Name:GILLEN, EUGENE
Entity type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:
Last Name:GILLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 OLD FRANCONIA RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-2529
Mailing Address - Country:US
Mailing Address - Phone:703-955-3703
Mailing Address - Fax:
Practice Address - Street 1:6210 OLD FRANCONIA RD UNIT A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-2529
Practice Address - Country:US
Practice Address - Phone:703-955-3703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA09040163721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program