Provider Demographics
NPI:1285916460
Name:GILLAM, S LENOIR (PHD)
Entity type:Individual
Prefix:DR
First Name:S
Middle Name:LENOIR
Last Name:GILLAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 UNIVERSITY AVE
Mailing Address - Street 2:SCHUSTER CENTER, THIRD FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-5679
Mailing Address - Country:US
Mailing Address - Phone:469-735-4555
Mailing Address - Fax:
Practice Address - Street 1:4225 UNIVERSITY AVE
Practice Address - Street 2:SCHUSTER CENTER, THIRD FLOOR
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-5679
Practice Address - Country:US
Practice Address - Phone:469-735-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002808103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling