Healthcare Provider Details

I. General information

NPI: 1063797546
Provider Name (Legal Business Name): MICHAEL J. GILLESPIE M.ED, CAADC, LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 ENTERPRISE DR
VASSAR MI
48768-9584
US

IV. Provider business mailing address

150 ENTERPRISE DR
VASSAR MI
48768-9584
US

V. Phone/Fax

Practice location:
  • Phone: 989-823-3040
  • Fax:
Mailing address:
  • Phone: 989-823-3040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801034056
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: