Provider Demographics
NPI:1710030663
Name:GULLEY, DALLAS R (LICSW)
Entity Type:Individual
Prefix:MR
First Name:DALLAS
Middle Name:R
Last Name:GULLEY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 WASHINGTON ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-4455
Mailing Address - Country:US
Mailing Address - Phone:781-329-0909
Mailing Address - Fax:781-320-9136
Practice Address - Street 1:450 WASHINGTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-4455
Practice Address - Country:US
Practice Address - Phone:781-329-0909
Practice Address - Fax:781-320-9136
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1030941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical