Provider Demographics
NPI:1568040822
Name:GULLINS, TAMICA MARIE (BACHELOR OF SCIENCE)
Entity Type:Individual
Prefix:
First Name:TAMICA
Middle Name:MARIE
Last Name:GULLINS
Suffix:
Gender:F
Credentials:BACHELOR OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 SPRING GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-3206
Mailing Address - Country:US
Mailing Address - Phone:215-769-3561
Mailing Address - Fax:215-769-3860
Practice Address - Street 1:1235 SPRING GARDEN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-3206
Practice Address - Country:US
Practice Address - Phone:215-769-3561
Practice Address - Fax:215-769-3860
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102486994001Medicaid