Provider Demographics
NPI:1831871094
Name:GILLIAM, KYLE MARCUS (LPC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:MARCUS
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:KYE
Other - Middle Name:M
Other - Last Name:GILLIAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4049 HAVERFORD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-1745
Mailing Address - Country:US
Mailing Address - Phone:267-559-2356
Mailing Address - Fax:
Practice Address - Street 1:4049 HAVERFORD AVE FL 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-1745
Practice Address - Country:US
Practice Address - Phone:215-839-6867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health