MEDICARE: SUSAN GENTZ GILLESPIE, LMFT

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	251S00000X	Community/Behavioral Health Agency	MFT 38572	CA
2	251S00000X	Community/Behavioral Health Agency	LMFT000140	DC

General Provider Information

NPI Number	:	1093074684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSAN GENTZ GILLESPIE, LMFT

Provider Business Mailing Address
First Line	:	1250 CONNECTICUT AVE NW
Second Line	:	SUITE 200
City	:	WASHINGTON
State	:	DC
Zip	:	20036-2603
Country	:	US
Telephone Number	:	415-609-8205
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 CONNECTICUT AVE NW
Second Line	:	SUITE 200
City	:	WASHINGTON
State	:	DC
Zip	:	20036-2603
Country	:	US
Telephone Number	:	415-609-8205
Fax Number	:

Authorized Official
Title or Position	:	PROPRIETOR
Name	:	MS. SUSAN GENTZ GILLESPIE
Credential	:	LMFT
Telephone Number	:	415-609-8205

Provider Enumeration Date	:	05/16/2012
Last Update Date	:	05/16/2012

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