Provider Demographics
NPI:1649365503
Name:GILLUM, DEBRA JAPZON (PHD)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:JAPZON
Last Name:GILLUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 PURDUE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5510
Mailing Address - Country:US
Mailing Address - Phone:901-867-8889
Mailing Address - Fax:901-867-8699
Practice Address - Street 1:1540 PURDUE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5510
Practice Address - Country:US
Practice Address - Phone:901-867-8889
Practice Address - Fax:901-867-8699
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1708103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000388Medicaid
NC0450TOtherBCBS
NC0450TOtherBCBS
NCOTH000Medicare UPIN