Basic Information
| Provider Information | |||||||||
| NPI: | 1669719951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLIAM | ||||||||
| FirstName: | FOY | ||||||||
| MiddleName: | BUTCH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 251970 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722251970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016668686 | ||||||||
| FaxNumber: | 5016606830 | ||||||||
| Practice Location | |||||||||
| Address1: | 1521 MERRILL DR STE E200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722111821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016606893 | ||||||||
| FaxNumber: | 5019747798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2013 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7908C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.