Provider Demographics
NPI:1811226665
Name:GILLAM, MAYA (LMT)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:GILLAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:MAYA
Other - Middle Name:
Other - Last Name:YUREVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12555 SW FIRST ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005
Mailing Address - Country:US
Mailing Address - Phone:503-619-6936
Mailing Address - Fax:
Practice Address - Street 1:12555 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005
Practice Address - Country:US
Practice Address - Phone:503-619-6936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist