Provider Demographics
NPI:1164096970
Name:GILLAM, TY'IONNA NICOLE
Entity Type:Individual
Prefix:
First Name:TY'IONNA
Middle Name:NICOLE
Last Name:GILLAM
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 1:1439 THUNDERBOLT DR
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-9341
Mailing Address - Country:US
Mailing Address - Phone:843-539-2211
Mailing Address - Fax:
Practice Address - Street 1:1439 THUNDERBOLT DR
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-9341
Practice Address - Country:US
Practice Address - Phone:843-539-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)