Provider Demographics
NPI:1154904159
Name:GILLIAM, ANTANISHA (RBT)
Entity type:Individual
Prefix:
First Name:ANTANISHA
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 MAIN LINE BLVD APT 306
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-2908
Mailing Address - Country:US
Mailing Address - Phone:703-864-1992
Mailing Address - Fax:
Practice Address - Street 1:6400 ARLINGTON BLVD STE 670
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-2336
Practice Address - Country:US
Practice Address - Phone:703-992-6938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-165773106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician