MEDICARE: BRANDON SCOTT GILLESPIE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1023649548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON SCOTT GILLESPIE

Provider Business Mailing Address
First Line	:	30685 BARRINGTON ST
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-5111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	30685 BARRINGTON ST
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-5111
Country	:	US
Telephone Number	:	248-965-3916
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2020
Last Update Date	:	03/07/2022

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