Provider Demographics
NPI:1598058588
Name:GILLIAM, KEITH (LMHC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 S HUNTINGTON AVE
Mailing Address - Street 2:APT 204
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 CUSHING AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-2028
Practice Address - Country:US
Practice Address - Phone:617-436-8600
Practice Address - Fax:617-282-2912
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7069101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health