Provider Demographics
NPI:1336426873
Name:GULLEY, CHARLES EDWARD
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:GULLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4729 HEMLOCK CIR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-1939
Mailing Address - Country:US
Mailing Address - Phone:405-474-0598
Mailing Address - Fax:
Practice Address - Street 1:4729 HEMLOCK CIR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-1939
Practice Address - Country:US
Practice Address - Phone:405-474-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health