Provider Demographics
NPI:1730651886
Name:GULLETTE, SIMONE SIMAS
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:SIMAS
Last Name:GULLETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1215
Mailing Address - Country:US
Mailing Address - Phone:917-683-6177
Mailing Address - Fax:
Practice Address - Street 1:70 SMITH ST
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940-1215
Practice Address - Country:US
Practice Address - Phone:917-683-6177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025672225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty