| Doctor Name: | MR. MICHAEL JOSEPH GILLEN |
| NPI Number: | 1477925121 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PH.D. |
| License Number: | 3313-57 |
| Business Practice Address: | 21425 Spring Street Union Grove Va Clinic Union Grove, WI - 53182 |
| Business Phone Number: | 2628787020 |
| Business Fax Number: | |
| Mailing Address: | 21425 Spring Street, Union Grove Va Clinic UNION GROVE |
| State: | WI |
| Postal Code: | 53182 |
| Phone Number: | 2628787020 |
| Fax Number: | |
| NPI Enumeration Date: | 10/21/2015 |
| NPI Last Update Date: | 10/21/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 3313-57 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |