Provider Demographics
NPI:1548326879
Name:GILLEN, JUSTINE MARY ANTON (PT)
Entity type:Individual
Prefix:MS
First Name:JUSTINE
Middle Name:MARY ANTON
Last Name:GILLEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E MAIN ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2911
Mailing Address - Country:US
Mailing Address - Phone:203-315-7727
Mailing Address - Fax:203-315-7757
Practice Address - Street 1:500 E MAIN ST
Practice Address - Street 2:SUITE 310
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2911
Practice Address - Country:US
Practice Address - Phone:203-315-7727
Practice Address - Fax:203-315-7757
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2266611OtherFIRST HEALTH
7820314OtherAETNA
CT080002869CT01OtherANTHEM B/C B/S
D400156582Medicare PIN