Provider Demographics
NPI:1578827382
Name:GILLIAM, MAYA ALFRIDRA (NC#11053)
Entity Type:Individual
Prefix:MS
First Name:MAYA
Middle Name:ALFRIDRA
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:NC#11053
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3028
Mailing Address - Country:US
Mailing Address - Phone:336-793-2991
Mailing Address - Fax:866-440-0711
Practice Address - Street 1:707 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3028
Practice Address - Country:US
Practice Address - Phone:336-793-2991
Practice Address - Fax:866-440-0711
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11053225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist