Provider Demographics
NPI:1013458041
Name:GILLUM, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:GILLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 S 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5794
Mailing Address - Country:US
Mailing Address - Phone:509-547-9000
Mailing Address - Fax:
Practice Address - Street 1:1020 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5794
Practice Address - Country:US
Practice Address - Phone:509-547-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60736147101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60736147OtherCOUNSELOR AGENCY AFFILIATED REGISTRATION