Provider Demographics
NPI:1346526670
Name:GULLEDGE, DENEQUA (PEER SPECIALIST)
Entity Type:Individual
Prefix:MS
First Name:DENEQUA
Middle Name:
Last Name:GULLEDGE
Suffix:
Gender:F
Credentials:PEER SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-2703
Mailing Address - Country:US
Mailing Address - Phone:313-867-8015
Mailing Address - Fax:313-867-8040
Practice Address - Street 1:300 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-2703
Practice Address - Country:US
Practice Address - Phone:313-867-8015
Practice Address - Fax:313-867-8040
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI143236940101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1437236940Medicaid