Provider Demographics
NPI:1194231118
Name:GILLAM, KRISTINA LYNN
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LYNN
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 1:61607 29 PALMS HWY STE D
Mailing Address - Street 2:
Mailing Address - City:JOSHUA TREE
Mailing Address - State:CA
Mailing Address - Zip Code:92252-2391
Mailing Address - Country:US
Mailing Address - Phone:760-366-8641
Mailing Address - Fax:760-366-3365
Practice Address - Street 1:61607 29 PALMS HWY STE D
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-2391
Practice Address - Country:US
Practice Address - Phone:760-366-8641
Practice Address - Fax:760-366-3365
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1265160917101YA0400X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)