Provider Demographics
NPI:1386108793
Name:QUILLIAM, DAVE (LMSW)
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:QUILLIAM
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-2015
Mailing Address - Country:US
Mailing Address - Phone:800-252-2065
Mailing Address - Fax:
Practice Address - Street 1:324 MEADOWS DR
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-2015
Practice Address - Country:US
Practice Address - Phone:800-252-2065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801082748207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine