Provider Demographics
NPI:1871647495
Name:GILLIAM, LINDA DIANE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:DIANE
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8905 JONQUIL
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-5716
Mailing Address - Country:US
Mailing Address - Phone:254-717-3328
Mailing Address - Fax:254-755-6001
Practice Address - Street 1:8905 JONQUIL
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-5716
Practice Address - Country:US
Practice Address - Phone:254-717-3328
Practice Address - Fax:254-755-6001
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX050681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S08ZMedicare ID - Type Unspecified