Provider Demographics
NPI:1407478928
Name:GILLIAM, BAILEY (LAC)
Entity Type:Individual
Prefix:MRS
First Name:BAILEY
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 N ALMA SCHOOL RD STE E
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4363
Mailing Address - Country:US
Mailing Address - Phone:480-641-1165
Mailing Address - Fax:
Practice Address - Street 1:17235 N 75TH AVE STE F100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-0871
Practice Address - Country:US
Practice Address - Phone:480-641-1165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC18882101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health