Provider Demographics
NPI:1972541688
Name:GILILLAND, WILLARD CLAY
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:CLAY
Last Name:GILILLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 CHESHIRE PKWY N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-4103
Mailing Address - Country:US
Mailing Address - Phone:763-268-4115
Mailing Address - Fax:763-268-4430
Practice Address - Street 1:13922 SEAL BEACH BLVD
Practice Address - Street 2:STE B
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-5387
Practice Address - Country:US
Practice Address - Phone:562-431-1512
Practice Address - Fax:562-493-2135
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA3166237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA0031660Medicaid