Provider Demographics
NPI:1841465283
Name:GILLIAM, RANDI MARIE (LMT)
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:MARIE
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 GRACE ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-3125
Mailing Address - Country:US
Mailing Address - Phone:864-223-1225
Mailing Address - Fax:
Practice Address - Street 1:446 GRACE ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-3125
Practice Address - Country:US
Practice Address - Phone:864-223-1225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5688174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist