Provider Demographics
NPI:1689188633
Name:GELISPIE, DEVETA KAMIL (LSW)
Entity Type:Individual
Prefix:
First Name:DEVETA
Middle Name:KAMIL
Last Name:GELISPIE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4853 S VINCENNES AVE UNIT 305
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-1478
Mailing Address - Country:US
Mailing Address - Phone:312-890-4205
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE BLDG 2284TH
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-4952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150101980104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker