Provider Demographics
NPI:1699192351
Name:GILLESPIE, KENNETH E (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:GILLESPIE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12126 N 79TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-8262
Mailing Address - Country:US
Mailing Address - Phone:623-806-6002
Mailing Address - Fax:
Practice Address - Street 1:12126 N 79TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-8262
Practice Address - Country:US
Practice Address - Phone:623-806-6002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZT169680225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist