Provider Demographics
NPI:1790271633
Name:GRESHAM, JILL ELIZABETH (RBT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ELIZABETH
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 HAMMOND DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5532
Mailing Address - Country:US
Mailing Address - Phone:678-753-5598
Mailing Address - Fax:
Practice Address - Street 1:750 HAMMOND DR STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5532
Practice Address - Country:US
Practice Address - Phone:678-753-5598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-16-20925261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health