Provider Demographics
NPI:1609112770
Name:GILLYARD, GLORIA
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:GILLYARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 KRAMME AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21225-3019
Mailing Address - Country:US
Mailing Address - Phone:443-418-8044
Mailing Address - Fax:
Practice Address - Street 1:5106 KRAMME AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MD
Practice Address - Zip Code:21225-3019
Practice Address - Country:US
Practice Address - Phone:443-418-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00805224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant