Provider Demographics
NPI:1487198560
Name:GILLIAM, KIRBY (MT-BC)
Entity Type:Individual
Prefix:MS
First Name:KIRBY
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-2207
Mailing Address - Country:US
Mailing Address - Phone:765-278-2030
Mailing Address - Fax:
Practice Address - Street 1:115 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-2207
Practice Address - Country:US
Practice Address - Phone:765-278-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12643225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist