MEDICARE: SHATOYA ESHELLE GILLIAM

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1902332737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHATOYA ESHELLE GILLIAM

Provider Business Mailing Address
First Line	:	1922 DRY CREEK WAY STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-1840
Country	:	US
Telephone Number	:	844-272-7223
Fax Number	:

Provider Business Practice Location Address
First Line	:	1922 DRY CREEK WAY STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-1840
Country	:	US
Telephone Number	:	844-272-7223
Fax Number	:

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

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	04/28/2023

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