Provider Demographics
NPI:1528480001
Name:GILLIAM, EMILY (LMFT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 N MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3877
Mailing Address - Country:US
Mailing Address - Phone:815-687-5600
Mailing Address - Fax:
Practice Address - Street 1:8616 NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5309
Practice Address - Country:US
Practice Address - Phone:812-332-8003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166000942106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist