MEDICARE: DR. MARISA GILLISPIE PT, DPT

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1922730100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARISA GILLISPIE PT, DPT

Provider Business Mailing Address
First Line	:	12105 PALM SPRINGS AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-5419
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8725 ALAMEDA PARK DR NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87113-2475
Country	:	US
Telephone Number	:	505-917-6144
Fax Number	:

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

Provider Enumeration Date	:	06/27/2022
Last Update Date	:	06/27/2022

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