Provider Demographics
NPI:1235345604
Name:GILLIAM, THERESA LYNN (MS, OTRL, CLT-LANA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:MS, OTRL, CLT-LANA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 BIRNAMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-9610
Mailing Address - Country:US
Mailing Address - Phone:919-967-8583
Mailing Address - Fax:
Practice Address - Street 1:187 BIRNAMWOOD DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516-9610
Practice Address - Country:US
Practice Address - Phone:919-967-8583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5631225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC186565OtherMEDCOST
NC1407MOtherBCBS NC
NC0443MOtherBCBSNC DME
NC2511227AMedicare PIN
NC0443MOtherBCBSNC DME
NC186565OtherMEDCOST