Basic Information
| Provider Information | |||||||||
| NPI: | 1366921462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLESPIE PRIEST | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | QMHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 COLUMBUS RD | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457011334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405926724 | ||||||||
| FaxNumber: | 7405926728 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 STATE ROUTE 143 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457101100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406980131 | ||||||||
| FaxNumber: | 7406980832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2018 | ||||||||
| LastUpdateDate: | 08/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 2314525 | 05 | OH | MEDICAID | 2864002 | 05 | OH | MEDICAID |