Provider Demographics
NPI:1841968708
Name:GILLIAM, LATESHIA ANN (LPC)
Entity type:Individual
Prefix:MS
First Name:LATESHIA
Middle Name:ANN
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E HICKS ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23868-1830
Mailing Address - Country:US
Mailing Address - Phone:434-253-5617
Mailing Address - Fax:
Practice Address - Street 1:102 E HICKS ST STE 100
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23868-1830
Practice Address - Country:US
Practice Address - Phone:434-253-5617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010711101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional