Provider Demographics
NPI:1093259137
Name:KATHERINE L. GILLISPIE, LCSW, BCBA
Entity Type:Organization
Organization Name:KATHERINE L. GILLISPIE, LCSW, BCBA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GILLISPIE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, BCBA
Authorized Official - Phone:406-529-9516
Mailing Address - Street 1:PO BOX 5814
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-5814
Mailing Address - Country:US
Mailing Address - Phone:406-529-9516
Mailing Address - Fax:888-978-6176
Practice Address - Street 1:415 NORTH HIGGINS AVENUE
Practice Address - Street 2:SUITE 111A
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-9926
Practice Address - Country:US
Practice Address - Phone:406-529-9516
Practice Address - Fax:888-978-6176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty