Provider Demographics
NPI:1457536385
Name:GILLIAM, TIMOTHY H (LPC, LMFT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:H
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:MABANK
Mailing Address - State:TX
Mailing Address - Zip Code:75156-7281
Mailing Address - Country:US
Mailing Address - Phone:903-340-2590
Mailing Address - Fax:903-451-2232
Practice Address - Street 1:300 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:MABANK
Practice Address - State:TX
Practice Address - Zip Code:75156-7281
Practice Address - Country:US
Practice Address - Phone:903-340-2590
Practice Address - Fax:903-451-2232
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61105101YP2500X
TX200951106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK-2959622Medicaid