Provider Demographics
NPI:1164545034
Name:GILLIAM, STEPHANIE L (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11922 SLOANE CT
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-2726
Mailing Address - Country:US
Mailing Address - Phone:703-860-0316
Mailing Address - Fax:703-860-0316
Practice Address - Street 1:6849 OLD DOMINION DR
Practice Address - Street 2:SUITE 221
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3724
Practice Address - Country:US
Practice Address - Phone:703-848-9333
Practice Address - Fax:703-848-0660
Is Sole Proprietor?:No
Enumeration Date:2007-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202432225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist