Healthcare Provider Details

I. General information

NPI: 1134110117
Provider Name (Legal Business Name): MR. CURTIS GILLESPIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3162 EL CAMINO DR
SPRINGFIELD OH
45503-1318
US

IV. Provider business mailing address

2475 WICKLIFFE RD
COLUMBUS OH
43221-1835
US

V. Phone/Fax

Practice location:
  • Phone: 937-342-9030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.964481
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.0001350-SUPV
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0001981-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: