Provider Demographics
NPI:1861525230
Name:GILLIS, STEPHANIE (LMFT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GILLIS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4925 CHARLESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-9426
Mailing Address - Country:US
Mailing Address - Phone:812-941-9200
Mailing Address - Fax:812-941-9205
Practice Address - Street 1:4925 CHARLESTOWN RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-9426
Practice Address - Country:US
Practice Address - Phone:812-941-9200
Practice Address - Fax:812-941-9205
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY556106H00000X
IN35001677A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000608641OtherANTHEM