Provider Demographics
NPI:1518696509
Name:GILLIAM, QUANEISHA (LRIC)
Entity Type:Individual
Prefix:MRS
First Name:QUANEISHA
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:LRIC
Other - Prefix:MISS
Other - First Name:QUANEISHA
Other - Middle Name:
Other - Last Name:ROCHELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:505 S INDEPENDENCE BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1150
Mailing Address - Country:US
Mailing Address - Phone:757-376-8167
Mailing Address - Fax:757-452-4447
Practice Address - Street 1:505 S INDEPENDENCE BLVD STE 213
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1150
Practice Address - Country:US
Practice Address - Phone:757-376-8167
Practice Address - Fax:757-452-4447
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704014490101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health