Provider Demographics
NPI:1790008878
Name:ALYSIA GILLIAM CONSULTING
Entity Type:Organization
Organization Name:ALYSIA GILLIAM CONSULTING
Other - Org Name:PEDIATRIC BEHAVIORAL SERVICES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BOARD CERTIFIED BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:ALYSIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-329-0028
Mailing Address - Street 1:1335 KINGSLEY AVE # 2472
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4507
Mailing Address - Country:US
Mailing Address - Phone:904-329-0028
Mailing Address - Fax:866-818-7176
Practice Address - Street 1:1335 KINGSLEY AVE # 2472
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4507
Practice Address - Country:US
Practice Address - Phone:904-329-0028
Practice Address - Fax:866-818-7176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019773100Medicaid