Provider Demographics
NPI:1720318314
Name:GILLILAND, SHAVAUN ERIN (LMT)
Entity type:Individual
Prefix:MS
First Name:SHAVAUN
Middle Name:ERIN
Last Name:GILLILAND
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 LOMAS BLVD NW
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1962
Mailing Address - Country:US
Mailing Address - Phone:505-967-5358
Mailing Address - Fax:
Practice Address - Street 1:1221 KILAUEA AVE STE 60
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4264
Practice Address - Country:US
Practice Address - Phone:808-687-0117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
NM6459174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174400000XOther Service ProvidersSpecialist