Provider Demographics
NPI:1063912822
Name:GILLHAM, KATRINA ANNETTE (MOTR/L)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:ANNETTE
Last Name:GILLHAM
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3447 NW 18TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73065-5988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:THOMAS
Practice Address - State:OK
Practice Address - Zip Code:73668
Practice Address - Country:US
Practice Address - Phone:405-397-5957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1829225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics