Provider Demographics
NPI:1558964353
Name:GILLIAM, HEATHER DAWN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:DAWN
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6646 S INDIANAPOLIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-2605
Mailing Address - Country:US
Mailing Address - Phone:918-260-2895
Mailing Address - Fax:
Practice Address - Street 1:6646 S INDIANAPOLIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-2605
Practice Address - Country:US
Practice Address - Phone:918-260-2895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1226103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist