Provider Demographics
NPI:1851838312
Name:GILLIAM, TRISTAN LYN (OTR)
Entity Type:Individual
Prefix:MS
First Name:TRISTAN
Middle Name:LYN
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5100 ELDORADO PKWY # 102-20
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-6510
Mailing Address - Country:US
Mailing Address - Phone:469-310-1700
Mailing Address - Fax:469-310-1701
Practice Address - Street 1:5855 MILTON ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-4202
Practice Address - Country:US
Practice Address - Phone:694-310-1700
Practice Address - Fax:469-310-1701
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115431225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist