MEDICARE: DR. HEATHER DAWN GILLIAM PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1226	OK

General Provider Information

NPI Number	:	1558964353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEATHER DAWN GILLIAM PSYD

Provider Business Mailing Address
First Line	:	6646 S INDIANAPOLIS AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-2605
Country	:	US
Telephone Number	:	918-260-2895
Fax Number	:

Provider Business Practice Location Address
First Line	:	6646 S INDIANAPOLIS AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-2605
Country	:	US
Telephone Number	:	918-260-2895
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2020
Last Update Date	:	11/16/2020

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