Basic Information
| Provider Information | |||||||||
| NPI: | 1851454300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLAM | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | CRAWFORD | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1933 BYRD RD | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038384455 | ||||||||
| FaxNumber: | 7038385070 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 N SAINT ASAPH ST | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223141912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038384455 | ||||||||
| FaxNumber: | 7038385070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0904005223 | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 270291 | 01 | VA | AMERIGROUP VIRGINIA INC. | OTHER | 188796 | 01 | VA | ANTHEM | OTHER |