MEDICARE: KELLY LAIRD-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	103TC1900X	Counseling Psychologist	NLC.0103641	CO
2	103TC1900X	Counseling Psychologist	LPC.0014348	CO

General Provider Information

NPI Number	:	1013378637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LAIRD-GILLESPIE

Provider Business Mailing Address
First Line	:	1802 CHAPEL HILLS DR STE F
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3736
Country	:	US
Telephone Number	:	719-695-0131
Fax Number	:

Provider Business Practice Location Address
First Line	:	1802 CHAPEL HILLS DR STE C
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3736
Country	:	US
Telephone Number	:	719-695-0131
Fax Number	:

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

Provider Enumeration Date	:	03/09/2016
Last Update Date	:	07/25/2021

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