Provider Demographics
NPI:1932690518
Name:GILLISPIE, KIRBY ODAWA
Entity Type:Individual
Prefix:
First Name:KIRBY
Middle Name:ODAWA
Last Name:GILLISPIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIRBY
Other - Middle Name:
Other - Last Name:ODAWA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:4881 WHITE ROCK CIR APT E
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3271
Mailing Address - Country:US
Mailing Address - Phone:805-591-9792
Mailing Address - Fax:
Practice Address - Street 1:4881 WHITE ROCK CIR APT E
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3271
Practice Address - Country:US
Practice Address - Phone:805-591-9792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-19
Last Update Date:2018-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health