Provider Demographics
NPI:1174688931
Name:GULLI, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GULLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 OLD SUNBEAM DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-4424
Mailing Address - Country:US
Mailing Address - Phone:386-846-4034
Mailing Address - Fax:
Practice Address - Street 1:134 OLD SUNBEAM DR
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-4424
Practice Address - Country:US
Practice Address - Phone:386-846-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW81011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691568096Medicaid
FL691568098Medicaid