Basic Information
| Provider Information | |||||||||
| NPI: | 1275124810 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLESPIE | ||||||||
| FirstName: | KIERAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 HOMECREST CT | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115722209 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 71 HOMECREST CT | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115722209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167666283 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2021 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | P118483 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.