Provider Demographics
NPI:1659686087
Name:GILLIAM, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
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 1:11 GARY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PARIS
Mailing Address - State:ME
Mailing Address - Zip Code:04281-1636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1570 MAIN ST STE 11
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:ME
Practice Address - Zip Code:04270-3390
Practice Address - Country:US
Practice Address - Phone:207-743-8972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP155235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist