Healthcare Provider Details

I. General information

NPI: 1922483577
Provider Name (Legal Business Name): VANESSA GILLIAM M.ED., BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 CEDAR SPRINGS RD
DALLAS TX
75219
US

IV. Provider business mailing address

12941 NORTH FREEWAY SUITE 750
HOUSTON TX
77060
US

V. Phone/Fax

Practice location:
  • Phone: 469-906-6372
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-49803
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: