Provider Demographics
NPI:1033475736
Name:GILLISPIE, KATHERINE L (LCSW, BCBA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:L
Last Name:GILLISPIE
Suffix:
Gender:F
Credentials:LCSW, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5814
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-5814
Mailing Address - Country:US
Mailing Address - Phone:406-529-9516
Mailing Address - Fax:
Practice Address - Street 1:210 N HIGGINS AVE STE 337
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4443
Practice Address - Country:US
Practice Address - Phone:406-529-9516
Practice Address - Fax:888-978-6176
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9641041C0700X
MT1-12-10348103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT77039Medicaid