Provider Demographics
NPI:1477949105
Name:GILLASPY, LORAN (RADT I)
Entity Type:Individual
Prefix:
First Name:LORAN
Middle Name:
Last Name:GILLASPY
Suffix:
Gender:M
Credentials:RADT I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 BOST AVE
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-3249
Mailing Address - Country:US
Mailing Address - Phone:530-265-9045
Mailing Address - Fax:530-478-7977
Practice Address - Street 1:145 BOST AVE
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-3249
Practice Address - Country:US
Practice Address - Phone:530-265-9045
Practice Address - Fax:530-478-7977
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1196130315324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility