Provider Demographics
NPI:1265260152
Name:GULLION, RANDA
Entity type:Individual
Prefix:
First Name:RANDA
Middle Name:
Last Name:GULLION
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 1:168 N JOHNSON ST
Mailing Address - Street 2:305
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:168 N JOHNSON ST
Practice Address - Street 2:#305
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132
Practice Address - Country:US
Practice Address - Phone:772-979-6988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-1277-631286106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician