Provider Demographics
NPI:1780166751
Name:GULEGIN, MARK (MA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GULEGIN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6332 CLAUSSEN WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660-4342
Mailing Address - Country:US
Mailing Address - Phone:916-977-0174
Mailing Address - Fax:
Practice Address - Street 1:1106 WINDFIELD WAY STE 1
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9360
Practice Address - Country:US
Practice Address - Phone:916-357-5837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-19-77919103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst