Provider Demographics
NPI:1164458808
Name:OLIVER-BRANNON, GAYLE (LLP)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:OLIVER-BRANNON
Suffix:
Gender:F
Credentials:LLP
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 1402
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48112-1402
Mailing Address - Country:US
Mailing Address - Phone:313-690-3837
Mailing Address - Fax:734-753-3276
Practice Address - Street 1:25 OWEN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-2921
Practice Address - Country:US
Practice Address - Phone:313-690-3837
Practice Address - Fax:734-753-3276
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003184103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral