Healthcare Provider Details

I. General information

NPI: 1730659301
Provider Name (Legal Business Name): GRANT THOMAS GILLIAM LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S ADAMS ST
BLOOMINGTON IN
47403-2165
US

IV. Provider business mailing address

550 S ADAMS ST
BLOOMINGTON IN
47403-2165
US

V. Phone/Fax

Practice location:
  • Phone: 812-333-6324
  • Fax: 812-331-6700
Mailing address:
  • Phone: 812-333-6324
  • Fax: 812-331-6700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39003932A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: