Provider Demographics
NPI:1124574421
Name:GILLUM, AZELIA OCTAVEE
Entity Type:Individual
Prefix:MISS
First Name:AZELIA
Middle Name:OCTAVEE
Last Name:GILLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 HEATHER LANE
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461
Mailing Address - Country:US
Mailing Address - Phone:402-517-1351
Mailing Address - Fax:
Practice Address - Street 1:2013 HEATHER LANE
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461
Practice Address - Country:US
Practice Address - Phone:402-517-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
LA222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist