Provider Demographics
NPI:1326553470
Name:GILLIAM, DAPHNE (BCABA)
Entity Type:Individual
Prefix:
First Name:DAPHNE
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6850 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:TROUTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24175-5919
Mailing Address - Country:US
Mailing Address - Phone:540-580-8790
Mailing Address - Fax:
Practice Address - Street 1:1138 2ND ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4725
Practice Address - Country:US
Practice Address - Phone:980-785-1113
Practice Address - Fax:980-785-1114
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-17-33544106S00000X
VA0134000251106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician