Provider Demographics
NPI:1508074287
Name:KILLAM, ANNE HAWTHORNE (MS)
Entity Type:Individual
Prefix:MRS
First Name:ANNE
Middle Name:HAWTHORNE
Last Name:KILLAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 NEELY AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-7530
Mailing Address - Country:US
Mailing Address - Phone:432-362-0049
Mailing Address - Fax:432-362-0046
Practice Address - Street 1:3500 N A ST
Practice Address - Street 2:SUITE 2400
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-2554
Practice Address - Country:US
Practice Address - Phone:432-550-5683
Practice Address - Fax:432-818-2176
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8797101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184757601Medicaid