Healthcare Provider Details

I. General information

NPI: 1639044506
Provider Name (Legal Business Name): MARYEDEH GILLESPIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

IV. Provider business mailing address

36051 GRAND RIVER AVE
FARMINGTON MI
48335-3032
US

V. Phone/Fax

Practice location:
  • Phone: 313-989-9444
  • Fax:
Mailing address:
  • Phone: 313-420-8606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: