Provider Demographics
NPI:1255308540
Name:GILLIAM, KATHLEEN ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANN
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 ALEXANDER ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-1920
Mailing Address - Country:US
Mailing Address - Phone:585-637-5902
Mailing Address - Fax:
Practice Address - Street 1:277 ALEXANDER ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1920
Practice Address - Country:US
Practice Address - Phone:585-637-5902
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP010013395-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11286BMedicare ID - Type Unspecified