Provider Demographics
NPI:1336378785
Name:GILLIAM, ALYSIA S (MS)
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:S
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4123 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE C
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4371
Mailing Address - Country:US
Mailing Address - Phone:904-329-3317
Mailing Address - Fax:904-329-3318
Practice Address - Street 1:4123 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4371
Practice Address - Country:US
Practice Address - Phone:904-329-3317
Practice Address - Fax:904-329-3318
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-09-6104103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst