Provider Demographics
NPI:1215571989
Name:GILLIAM, ELLIOT
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3195 M ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-2406
Mailing Address - Country:US
Mailing Address - Phone:209-723-6030
Mailing Address - Fax:209-723-6032
Practice Address - Street 1:3195 M ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2406
Practice Address - Country:US
Practice Address - Phone:209-723-6030
Practice Address - Fax:209-723-6032
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health