Basic Information
| Provider Information | |||||||||
| NPI: | 1598155251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLISPIE | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CDP - TRAINEE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAYBERRY | ||||||||
| OtherFirstName: | BONNIE | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 369 | ||||||||
| Address2: | |||||||||
| City: | STEVENSON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094273850 | ||||||||
| FaxNumber: | 5094270188 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 SW ROCK CREEK DR. | ||||||||
| Address2: | |||||||||
| City: | STEVENSON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094273850 | ||||||||
| FaxNumber: | 5094270188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2015 | ||||||||
| LastUpdateDate: | 05/11/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CG60451727 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | CP60474384 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.