Provider Demographics
NPI:1952852170
Name:GULLY, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GULLY
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 1:3201 KNIGHT ST.
Mailing Address - Street 2:APT. 207
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105
Mailing Address - Country:US
Mailing Address - Phone:318-415-9012
Mailing Address - Fax:
Practice Address - Street 1:3201 KNIGHT ST
Practice Address - Street 2:APT. 207
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2706
Practice Address - Country:US
Practice Address - Phone:318-415-9012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor