Provider Demographics
NPI:1780130674
Name:VERTULA, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:VERTULA
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 1:260 ROBIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4440
Mailing Address - Country:US
Mailing Address - Phone:203-394-2595
Mailing Address - Fax:203-332-1629
Practice Address - Street 1:260 ROBIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4440
Practice Address - Country:US
Practice Address - Phone:203-394-2595
Practice Address - Fax:203-332-1629
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001749101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional