Provider Demographics
NPI:1831233824
Name:GILLAM, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GILLAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3563 S STATE ROAD 13
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-9162
Mailing Address - Country:US
Mailing Address - Phone:260-563-8453
Mailing Address - Fax:260-569-0335
Practice Address - Street 1:3409 S 200 W
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-9613
Practice Address - Country:US
Practice Address - Phone:260-563-8453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001976101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201097990Medicaid