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General NPI Number Information
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NPI Number | 1912464140
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Entity Type | Organization
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Legal Business Name | CORLISS GILLESPIE, LLC
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Dates
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Enumeration Date | 02/24/2019
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Last Update Date | 02/24/2019
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Provider Practice Location Address
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Address Line | 12531 CLIPPER DR
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City | WOODBRIDGE
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State | VA
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Zip | 22192-2355
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Country | US
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Telephone | 571-402-2509
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4090
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City | WOODBRIDGE
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State | VA
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Zip | 22194-4090
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CORLISS GILLESPIE
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Credential | LPC
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Telephone | 571-402-2509
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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