Provider Demographics
NPI:1497030704
Name:GULLETT, MATT R (MA, LMHC, MHP)
Entity Type:Individual
Prefix:MR
First Name:MATT
Middle Name:R
Last Name:GULLETT
Suffix:
Gender:M
Credentials:MA, LMHC, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 YAKIMA AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4457
Mailing Address - Country:US
Mailing Address - Phone:253-502-2699
Mailing Address - Fax:253-502-2757
Practice Address - Street 1:1323 YAKIMA AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4457
Practice Address - Country:US
Practice Address - Phone:253-502-2699
Practice Address - Fax:253-502-2757
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60474055101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health