Provider Demographics
NPI:1891458980
Name:GILLAM, JOSEPH WILLIAM (LMT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:WILLIAM
Last Name:GILLAM
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8624 SE 17TH AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7387
Mailing Address - Country:US
Mailing Address - Phone:607-793-3193
Mailing Address - Fax:
Practice Address - Street 1:8311 SE 13TH AVE STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7170
Practice Address - Country:US
Practice Address - Phone:971-202-0554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23871225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist