Healthcare Provider Details

I. General information

NPI: 1295062255
Provider Name (Legal Business Name): STEPHEN GILLIAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 BEVILLE RD SUITE G
SOUTH DAYTONA FL
32119-1712
US

IV. Provider business mailing address

390 GLENWOOD DR
ATHENS GA
30606-4620
US

V. Phone/Fax

Practice location:
  • Phone: 386-756-4395
  • Fax: 866-426-2811
Mailing address:
  • Phone: 386-756-4395
  • Fax: 866-426-2811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA000967
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: