Provider Demographics
NPI:1790430627
Name:GULAU, JILL M
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:GULAU
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 1:1178 E MULLETT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49749-9514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:945 BARLOW ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4250
Practice Address - Country:US
Practice Address - Phone:231-268-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician