Provider Demographics
NPI:1225470834
Name:GILLIAM, JUSTIN JACOB (BSW)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:JACOB
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 NAUGATUCK AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-6036
Mailing Address - Country:US
Mailing Address - Phone:203-508-5053
Mailing Address - Fax:
Practice Address - Street 1:179 NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-1057
Practice Address - Country:US
Practice Address - Phone:413-529-9047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker