Provider Demographics
NPI:1861746273
Name:GILLESPIE, MICHAEL (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:GILLESPIE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 ONYX LAKE DR
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640
Mailing Address - Country:US
Mailing Address - Phone:210-781-4810
Mailing Address - Fax:
Practice Address - Street 1:6032 FM 3009
Practice Address - Street 2:#130
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154
Practice Address - Country:US
Practice Address - Phone:210-781-4810
Practice Address - Fax:210-314-1145
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1221966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1221966OtherEXECUTIVE COUNCIL OF PHYSICAL THERAPY LICENSE