Provider Demographics
NPI:1265416770
Name:GULLETT, HARLEY V (ACSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:HARLEY
Middle Name:V
Last Name:GULLETT
Suffix:
Gender:M
Credentials:ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S PREWITT ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-1760
Mailing Address - Country:US
Mailing Address - Phone:417-667-8700
Mailing Address - Fax:417-667-7382
Practice Address - Street 1:100 S PREWITT ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-1760
Practice Address - Country:US
Practice Address - Phone:417-667-8700
Practice Address - Fax:417-667-7382
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0004401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOL432586Medicare ID - Type Unspecified
MOR30524Medicare UPIN