Provider Demographics
NPI:1649782483
Name:GULLEY, MARVIN
Entity type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:
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 1:21 E. BEACON ST
Mailing Address - Street 2:F
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801
Mailing Address - Country:US
Mailing Address - Phone:213-444-8374
Mailing Address - Fax:213-382-0136
Practice Address - Street 1:360 S WESTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2906
Practice Address - Country:US
Practice Address - Phone:213-483-9201
Practice Address - Fax:213-382-0136
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR122472016101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty