Provider Demographics
NPI:1952462194
Name:GILLAM, CORTNEY CARMODY (LMP)
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:CARMODY
Last Name:GILLAM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-3356
Mailing Address - Country:US
Mailing Address - Phone:360-696-4580
Mailing Address - Fax:360-735-7626
Practice Address - Street 1:501 E MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3356
Practice Address - Country:US
Practice Address - Phone:360-696-4580
Practice Address - Fax:360-735-7626
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017364225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist