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General NPI Number Information
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NPI Number | 1699637686
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Entity Type | Individual
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Provider Name | LAVAR GILLIAM LMT
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Gender | Male
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Dates
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Enumeration Date | 11/27/2025
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Last Update Date | 11/27/2025
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Provider Practice Location Address
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Address Line | 10383 STONE PINE AVE
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City | WALDORF
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State | MD
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Zip | 20603-5795
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Country | US
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Telephone | 240-650-8967
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Fax |
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Provider Business Mailing Address
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Address Line | 1282 SMALLWOOD DR W # 193
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City | WALDORF
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State | MD
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Zip | 20603-4732
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 0019010499
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | M06984
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License Number State | MD
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