Provider Demographics
NPI:1780160283
Name:GALLIVAN, JULIE E
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:E
Last Name:GALLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:BAILEY
Mailing Address - State:MI
Mailing Address - Zip Code:49303-9782
Mailing Address - Country:US
Mailing Address - Phone:616-432-7551
Mailing Address - Fax:
Practice Address - Street 1:11 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:MI
Practice Address - Zip Code:49327-7900
Practice Address - Country:US
Practice Address - Phone:231-834-0444
Practice Address - Fax:231-834-0200
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016694101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional