Provider Demographics
NPI:1982738563
Name:HILLAM, MICHAEL LOREN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LOREN
Last Name:HILLAM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4696 W OVERLAND RD
Mailing Address - Street 2:STE 156
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2878
Mailing Address - Country:US
Mailing Address - Phone:208-577-6617
Mailing Address - Fax:208-577-6617
Practice Address - Street 1:4696 W OVERLAND RD STE 156
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2878
Practice Address - Country:US
Practice Address - Phone:208-577-6617
Practice Address - Fax:208-577-6617
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202427103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1620019Medicare UPIN