Provider Demographics
NPI:1932684487
Name:GILLUM, FREDRICK RANDAL (PSYD, LPC)
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:RANDAL
Last Name:GILLUM
Suffix:
Gender:M
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4814 MILL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77521-4127
Mailing Address - Country:US
Mailing Address - Phone:832-597-7337
Mailing Address - Fax:
Practice Address - Street 1:2656 S LOOP W STE 250
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-5645
Practice Address - Country:US
Practice Address - Phone:713-337-2457
Practice Address - Fax:713-337-2858
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76702101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional