Provider Demographics
NPI:1235558180
Name:GULLY, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GULLY
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 1:177 W PRICE AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4345
Mailing Address - Country:US
Mailing Address - Phone:385-468-4548
Mailing Address - Fax:
Practice Address - Street 1:177 W PRICE AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-4345
Practice Address - Country:US
Practice Address - Phone:385-468-4548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000316Medicaid