Provider Demographics
NPI:1598880320
Name:GULLY, ALEXIS MICHAEL (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ALEXIS
Middle Name:MICHAEL
Last Name:GULLY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MRS
Other - First Name:ALEXIS
Other - Middle Name:MICHAEL
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:7334 HARBOUR ISLE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-3471
Mailing Address - Country:US
Mailing Address - Phone:801-694-3836
Mailing Address - Fax:
Practice Address - Street 1:25 BEACHWAY DR
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-8506
Practice Address - Country:US
Practice Address - Phone:317-788-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT379250-35011041C0700X
IN34005217A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical