Provider Demographics
NPI:1083408181
Name:GILLISPIE, CHARLES L
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:GILLISPIE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S SPRING ST
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26362-1347
Mailing Address - Country:US
Mailing Address - Phone:304-266-7335
Mailing Address - Fax:
Practice Address - Street 1:410 S SPRING ST
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:WV
Practice Address - Zip Code:26362-1347
Practice Address - Country:US
Practice Address - Phone:304-266-7335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-05
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker