Provider Demographics
NPI:1720561251
Name:GILLESPIE, SHANNON LAUREL (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LAUREL
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LAUREL
Other - Last Name:OLLIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 715202
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-0001
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2639
Practice Address - Country:US
Practice Address - Phone:614-722-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.07769103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid