Provider Demographics
NPI:1992743371
Name:GILLEN, PETER J (PSYD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:GILLEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 VETERANS MEMORIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-5061
Mailing Address - Country:US
Mailing Address - Phone:402-432-1284
Mailing Address - Fax:401-432-1509
Practice Address - Street 1:1011 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02915-5061
Practice Address - Country:US
Practice Address - Phone:402-432-1533
Practice Address - Fax:401-432-1500
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00823103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPG70349Medicaid
RI9613312OtherAETNA HEALTHCARE