Provider Demographics
NPI:1629594197
Name:GILLIAM, GERREKA
Entity Type:Individual
Prefix:
First Name:GERREKA
Middle Name:
Last Name:GILLIAM
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 1:7381 LA TIJERA BLVD UNIT 452143
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-7099
Mailing Address - Country:US
Mailing Address - Phone:323-301-3449
Mailing Address - Fax:213-481-1776
Practice Address - Street 1:200 CORPORATE POINT WALK SUITE 325
Practice Address - Street 2:
Practice Address - City:CLOVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230
Practice Address - Country:US
Practice Address - Phone:323-301-3449
Practice Address - Fax:213-481-1776
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106613106H00000X
390200000X
CA136323106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program