Healthcare Provider Details

I. General information

NPI: 1174158331
Provider Name (Legal Business Name): HAILEY ELIZABETH GILLAM MA, BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 CASCADE RD SE
GRAND RAPIDS MI
49546-8384
US

IV. Provider business mailing address

4234 CASCADE RD SE
GRAND RAPIDS MI
49546-8384
US

V. Phone/Fax

Practice location:
  • Phone: 574-904-9433
  • Fax: 844-272-7692
Mailing address:
  • Phone: 574-904-9433
  • Fax: 844-272-7692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-115122
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401003258
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-61107
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number11307
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: