Provider Demographics
NPI:1356626253
Name:GILLIAM-ANDRES, MARY (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GILLIAM-ANDRES
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GILLIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5675 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-1033
Mailing Address - Country:US
Mailing Address - Phone:269-429-7727
Mailing Address - Fax:269-429-5754
Practice Address - Street 1:5675 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-1033
Practice Address - Country:US
Practice Address - Phone:269-429-7727
Practice Address - Fax:269-429-5754
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012360101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional