Provider Demographics
NPI:1437330669
Name:GILLHAM, CHAD ELLERY
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:ELLERY
Last Name:GILLHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4587 CTY RD 670
Mailing Address - Street 2:
Mailing Address - City:BROSELEY
Mailing Address - State:MO
Mailing Address - Zip Code:63932
Mailing Address - Country:US
Mailing Address - Phone:573-328-4471
Mailing Address - Fax:
Practice Address - Street 1:1510 BYRUM RD
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-8033
Practice Address - Country:US
Practice Address - Phone:870-532-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A504224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant