Provider Demographics
NPI:1013105295
Name:GATES-GULLY, MARY (MS, CADC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GATES-GULLY
Suffix:
Gender:F
Credentials:MS, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 E. MARTIN LUTHER KING DRIVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801
Mailing Address - Country:US
Mailing Address - Phone:618-533-1391
Mailing Address - Fax:618-533-0012
Practice Address - Street 1:904 E. MARTIN LUTHER KING DRIVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-533-1391
Practice Address - Fax:618-533-0012
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL21816101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370915481007Medicaid