Provider Demographics
NPI:1750966214
Name:GULLETT, SHAUNA (CDCA 177413, ASC)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:GULLETT
Suffix:
Gender:F
Credentials:CDCA 177413, ASC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 E HOME RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2520
Mailing Address - Country:US
Mailing Address - Phone:937-390-8060
Mailing Address - Fax:
Practice Address - Street 1:2317 E HOME RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2520
Practice Address - Country:US
Practice Address - Phone:937-390-8060
Practice Address - Fax:937-399-9070
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.171414101YA0400X
OHCDCA.177413101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0461765Medicaid