Provider Demographics
NPI:1144964560
Name:GULLET, MARY ROSE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:GULLET
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 1:11268 CR 682
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:FL
Mailing Address - Zip Code:33597-7455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36178 GRESHAM RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:FL
Practice Address - Zip Code:33597-9287
Practice Address - Country:US
Practice Address - Phone:813-449-2500
Practice Address - Fax:352-559-4420
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty