Provider Demographics
NPI:1932304052
Name:GULSETH, MYRON JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:JOHN
Last Name:GULSETH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13851 EAST 14TH STREET
Mailing Address - Street 2:DOCTORS OFFICE BUILDING SUITE 203
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578
Mailing Address - Country:US
Mailing Address - Phone:510-483-7100
Mailing Address - Fax:510-351-4328
Practice Address - Street 1:13851 EAST 14TH STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578
Practice Address - Country:US
Practice Address - Phone:510-483-7100
Practice Address - Fax:510-351-4328
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14885103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical