Provider Demographics
NPI:1871914689
Name:GILLESPIE, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:GILLESPIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-6611
Mailing Address - Country:US
Mailing Address - Phone:740-814-0048
Mailing Address - Fax:
Practice Address - Street 1:65 MESSIMER DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1874
Practice Address - Country:US
Practice Address - Phone:740-522-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0031525-S1041C0700X
OH111012-CS101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH111012-CSOtherLICDC-CS
OHI.0031525-SOtherLISW-S
OH0200008Medicaid