Provider Demographics
NPI:1326397779
Name:GILLUM, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:GILLUM
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 1:888 W BIG BEAVER RD STE 780
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4745
Mailing Address - Country:US
Mailing Address - Phone:810-964-2359
Mailing Address - Fax:
Practice Address - Street 1:888 W BIG BEAVER RD STE 780
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4745
Practice Address - Country:US
Practice Address - Phone:810-964-2359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004126235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist