Provider Demographics
NPI:1710014246
Name:GILLIOM, MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GILLIOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 N HARRISON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-2410
Mailing Address - Country:US
Mailing Address - Phone:919-677-0101
Mailing Address - Fax:919-677-0113
Practice Address - Street 1:1903 N HARRISON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-2410
Practice Address - Country:US
Practice Address - Phone:919-677-0101
Practice Address - Fax:919-677-0113
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3270103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical