Provider Demographics
NPI:1417656430
Name:GILLIAM, AJA
Entity type:Individual
Prefix:
First Name:AJA
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6835 SPRAGUE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1421
Mailing Address - Country:US
Mailing Address - Phone:215-820-2415
Mailing Address - Fax:
Practice Address - Street 1:110 CHURCH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-2201
Practice Address - Country:US
Practice Address - Phone:267-807-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst