Provider Demographics
NPI:1063043040
Name:VILA-GILLAM, EMMA
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:VILA-GILLAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 IVY RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08010-2619
Mailing Address - Country:US
Mailing Address - Phone:267-455-1227
Mailing Address - Fax:
Practice Address - Street 1:1080 N DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-4330
Practice Address - Country:US
Practice Address - Phone:215-496-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH003002103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst