Healthcare Provider Details

I. General information

NPI: 1992670913
Provider Name (Legal Business Name): STEFFEN GLENN GILLOM PHD, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2025
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 EAST AVE UNIT 8
WARWICK RI
02886-0500
US

IV. Provider business mailing address

643 EAST AVE UNIT 8
WARWICK RI
02886-0500
US

V. Phone/Fax

Practice location:
  • Phone: 401-310-3856
  • Fax:
Mailing address:
  • Phone: 401-310-3856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT00316
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: