Provider Demographics
NPI:1578704078
Name:PULLIAM, GRACIELA RUTH (MA LMHC)
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:RUTH
Last Name:PULLIAM
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3467 HEATH DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-3098
Mailing Address - Country:US
Mailing Address - Phone:321-578-7488
Mailing Address - Fax:
Practice Address - Street 1:2425 S VOLUSIA AVE STE B4
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7625
Practice Address - Country:US
Practice Address - Phone:321-578-7488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9913101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014378900Medicaid