Provider Demographics
NPI:1518347343
Name:GILLIAM, MARY L A (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L A
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17284 SLOVER AVE
Mailing Address - Street 2:SUITE #105
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-7584
Mailing Address - Country:US
Mailing Address - Phone:909-609-2800
Mailing Address - Fax:909-609-3805
Practice Address - Street 1:17284 SLOVER AVE
Practice Address - Street 2:SUITE #105
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-7584
Practice Address - Country:US
Practice Address - Phone:909-609-2800
Practice Address - Fax:909-609-3805
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-06
Last Update Date:2015-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS143261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical