Healthcare Provider Details

I. General information

NPI: 1245220227
Provider Name (Legal Business Name): ROBERT WILLSON GILLEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 WASHINGTON AVENUE EXT
ALBANY NY
12205-5534
US

IV. Provider business mailing address

215 WASHINGTON AVENUE EXT
ALBANY NY
12205-5534
US

V. Phone/Fax

Practice location:
  • Phone: 518-452-0914
  • Fax: 518-452-5953
Mailing address:
  • Phone: 518-452-0914
  • Fax: 518-452-5953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number007574
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number7574
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: