Provider Demographics
NPI:1811369606
Name:GULLO-BAKOWSKI, MICHELE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:GULLO-BAKOWSKI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7540 SALT RD
Mailing Address - Street 2:
Mailing Address - City:CLARENCE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14032-9655
Mailing Address - Country:US
Mailing Address - Phone:716-868-9975
Mailing Address - Fax:
Practice Address - Street 1:10440 MAIN ST
Practice Address - Street 2:STE 2
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14031-1627
Practice Address - Country:US
Practice Address - Phone:716-868-9975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025754225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist