Provider Demographics
NPI:1114201902
Name:GILLIAM, MONICA (LAC, EAMP,)
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:LAC, EAMP,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5605
Mailing Address - Country:US
Mailing Address - Phone:206-353-6403
Mailing Address - Fax:
Practice Address - Street 1:6700 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117-5507
Practice Address - Country:US
Practice Address - Phone:206-784-3493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60246513171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist