Provider Demographics
NPI:1134478787
Name:GILLESPIE, AMANDA M (LISW-S)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 N RIDGE RD E
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-3300
Mailing Address - Country:US
Mailing Address - Phone:440-462-1538
Mailing Address - Fax:440-324-0070
Practice Address - Street 1:1865 N RIDGE RD E
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-3300
Practice Address - Country:US
Practice Address - Phone:440-462-1538
Practice Address - Fax:440-324-0070
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.600782-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid