Provider Demographics
NPI:1568154185
Name:GULLEY, CLINTON III
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:GULLEY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20335 W COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1600
Mailing Address - Country:US
Mailing Address - Phone:786-877-5256
Mailing Address - Fax:
Practice Address - Street 1:7301 W PALMETTO PARK RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3458
Practice Address - Country:US
Practice Address - Phone:954-248-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-274315106S00000X
FL-23-274315106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician