Provider Demographics
NPI:1558686642
Name:GULLY, JANICE
Entity Type:Individual
Prefix:
First Name:JANICE
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 1:82 MEADOWMERE AVE
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-4606
Mailing Address - Country:US
Mailing Address - Phone:631-924-4411
Mailing Address - Fax:
Practice Address - Street 1:82 MEADOWMERE AVE
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-4606
Practice Address - Country:US
Practice Address - Phone:631-924-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist