Basic Information
| Provider Information | |||||||||
| NPI: | 1013458041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLUM | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 S 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993015794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095479000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1020 S 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993015794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095479000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2017 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
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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 | 101YM0800X | CG60736147 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | CG60736147 | 01 | WA | COUNSELOR AGENCY AFFILIATED REGISTRATION | OTHER |