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General NPI Number Information
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NPI Number | 1932684487
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Entity Type | Individual
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Provider Name | FREDRICK RANDAL GILLUM PSY.D, LPC
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Gender | Male
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Dates
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Enumeration Date | 10/01/2018
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Last Update Date | 10/01/2018
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Provider Practice Location Address
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Address Line | 2656 S LOOP W STE 250
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City | HOUSTON
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State | TX
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Zip | 77054-5645
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Country | US
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Telephone | 713-337-2457
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Fax | 713-337-2858
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Provider Business Mailing Address
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Address Line | 4814 MILL CREEK DR
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City | BAYTOWN
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State | TX
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Zip | 77521-4127
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Country | US
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Telephone | 832-597-7337
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 76702
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License Number State | TX
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