Provider Demographics
NPI:1972757508
Name:GILLEN, JANICE MAE (LMSW-CC)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:MAE
Last Name:GILLEN
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 EXCHANGE ST
Mailing Address - Street 2:NEW LIFE MISSION DBA BANGOR COUNSELING CENTER
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6508
Mailing Address - Country:US
Mailing Address - Phone:207-941-6434
Mailing Address - Fax:
Practice Address - Street 1:202 EXCHANGE ST
Practice Address - Street 2:NEW LIFE MISSION DBA BANGOR COUNSELING CENTER
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6508
Practice Address - Country:US
Practice Address - Phone:207-941-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC118671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMC11867OtherBOARD OF SOCIAL WORK LICENSURE