Provider Demographics
NPI:1033707492
Name:GILLIAM, DARWIN ANDRE
Entity Type:Individual
Prefix:
First Name:DARWIN
Middle Name:ANDRE
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8928 VOLUNTEER LN
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3238
Mailing Address - Country:US
Mailing Address - Phone:916-344-0199
Mailing Address - Fax:
Practice Address - Street 1:8928 VOLUNTEER LN
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3238
Practice Address - Country:US
Practice Address - Phone:916-344-0199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker