Provider Demographics
NPI:1194789180
Name:GILLUM, MICHAEL WILLIAM (MA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:GILLUM
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 WASHINGTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-5355
Mailing Address - Country:US
Mailing Address - Phone:570-321-6390
Mailing Address - Fax:570-321-6393
Practice Address - Street 1:705 WASHINGTON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-5355
Practice Address - Country:US
Practice Address - Phone:570-321-6390
Practice Address - Fax:570-321-6393
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007825L103TC2200X, 103T00000X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001553383Medicaid