Provider Demographics
NPI:1760775647
Name:GILLHAM, DEBORAH J (LMP, CCST)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
Last Name:GILLHAM
Suffix:
Gender:F
Credentials:LMP, CCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24111 122ND ST E
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98321-9575
Mailing Address - Country:US
Mailing Address - Phone:253-224-8875
Mailing Address - Fax:
Practice Address - Street 1:4103 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4300
Practice Address - Country:US
Practice Address - Phone:253-460-1824
Practice Address - Fax:253-460-1920
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024203174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist