Provider Demographics
NPI:1235253758
Name:GILLESPIE-OTTO, DANETTE CHARISSE (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DANETTE
Middle Name:CHARISSE
Last Name:GILLESPIE-OTTO
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MS
Other - First Name:DANETTE
Other - Middle Name:CHARISSE
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:911 SE 60TH AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2834
Mailing Address - Country:US
Mailing Address - Phone:503-482-8982
Mailing Address - Fax:
Practice Address - Street 1:333 NE RUSSELL ST STE 209
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3762
Practice Address - Country:US
Practice Address - Phone:503-482-8982
Practice Address - Fax:503-716-4742
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL40201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500673411Medicaid