Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | 6801103633 | MI |
NPI | 1003420498 |
---|---|
Provider Name | Justin Travis Gillespie |
First Address | Auburn Hills, MI 48326-2617 |
Second Address | Auburn Hills, MI 48326-2617 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2020 |
Last Update Date | 02/09/2020 |