Provider Demographics
NPI:1609371657
Name:GILLIAM, ANDREW S
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:S
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 KENNEDY LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503
Mailing Address - Country:US
Mailing Address - Phone:903-832-4327
Mailing Address - Fax:903-832-0921
Practice Address - Street 1:3101 KENNEDY LN
Practice Address - Street 2:SUITE 300
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503
Practice Address - Country:US
Practice Address - Phone:903-832-4327
Practice Address - Fax:903-832-0921
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80703TX237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist