Provider Demographics
NPI:1659783959
Name:GILLUM, KATHY (MSCJ)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:GILLUM
Suffix:
Gender:F
Credentials:MSCJ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4849 US HIGHWAY 160
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-7659
Mailing Address - Country:US
Mailing Address - Phone:417-818-6480
Mailing Address - Fax:417-428-2325
Practice Address - Street 1:4849 US HIGHWAY 160
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-7659
Practice Address - Country:US
Practice Address - Phone:417-818-6480
Practice Address - Fax:417-428-2325
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator