MEDICARE: DR. S LENOIR GILLAM PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	LPC002808	GA

General Provider Information

NPI Number	:	1285916460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. S LENOIR GILLAM PHD

Provider Business Mailing Address
First Line	:	4225 UNIVERSITY AVE
Second Line	:	SCHUSTER CENTER, THIRD FLOOR
City	:	COLUMBUS
State	:	GA
Zip	:	31907-5679
Country	:	US
Telephone Number	:	469-735-4555
Fax Number	:

Provider Business Practice Location Address
First Line	:	4225 UNIVERSITY AVE
Second Line	:	SCHUSTER CENTER, THIRD FLOOR
City	:	COLUMBUS
State	:	GA
Zip	:	31907-5679
Country	:	US
Telephone Number	:	469-735-4555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2011
Last Update Date	:	09/14/2011

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