Provider Demographics
NPI:1700608320
Name:GILLIAM, DEMARCIO MIKEL
Entity type:Individual
Prefix:
First Name:DEMARCIO
Middle Name:MIKEL
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 IVY LAKE LN
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-2782
Mailing Address - Country:US
Mailing Address - Phone:901-216-4119
Mailing Address - Fax:
Practice Address - Street 1:7900 IVY LAKE LN
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-2782
Practice Address - Country:US
Practice Address - Phone:901-216-4119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker