Provider Demographics
NPI:1598155251
Name:GILLISPIE, BONNIE KAY (CDP - TRAINEE)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:KAY
Last Name:GILLISPIE
Suffix:
Gender:F
Credentials:CDP - TRAINEE
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:KAY
Other - Last Name:MAYBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:STEVENSON
Mailing Address - State:WA
Mailing Address - Zip Code:98648
Mailing Address - Country:US
Mailing Address - Phone:509-427-3850
Mailing Address - Fax:509-427-0188
Practice Address - Street 1:710 SW ROCK CREEK DR.
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:WA
Practice Address - Zip Code:98648
Practice Address - Country:US
Practice Address - Phone:509-427-3850
Practice Address - Fax:509-427-0188
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60451727101YA0400X
WACP60474384101YA0400X
WAC060189064101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)