Healthcare Provider Details

I. General information

NPI: 1518318914
Provider Name (Legal Business Name): STEPHEN GILLES MSED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S MAIN AVE
PLATTE SD
57369-2117
US

IV. Provider business mailing address

612 S MAIN AVE P.O. BOX 128
PLATTE SD
57369-2117
US

V. Phone/Fax

Practice location:
  • Phone: 605-337-2636
  • Fax: 605-337-2271
Mailing address:
  • Phone: 605-337-2636
  • Fax: 605-337-2271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number#055569-01
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: