Provider Demographics
NPI:1013207869
Name:GILLIAM, LAURYN SALASSI (MS, PHD CANDIDATE)
Entity Type:Individual
Prefix:
First Name:LAURYN
Middle Name:SALASSI
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:MS, PHD CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3471 N FEDERAL HWY
Mailing Address - Street 2:#410
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1019
Mailing Address - Country:US
Mailing Address - Phone:305-725-0070
Mailing Address - Fax:
Practice Address - Street 1:3471 N FEDERAL HWY
Practice Address - Street 2:#410
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1019
Practice Address - Country:US
Practice Address - Phone:305-725-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 2562106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist