Provider Demographics
NPI:1356539456
Name:GILLAM, SANDRA LAING (SANDRA GILLAM)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:LAING
Last Name:GILLAM
Suffix:
Gender:F
Credentials:SANDRA GILLAM
Other - Prefix:DR
Other - First Name:SANDI
Other - Middle Name:
Other - Last Name:GILLAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1028 EASTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4990
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1028 EASTRIDGE DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4990
Practice Address - Country:US
Practice Address - Phone:435-753-9629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist