Provider Demographics
NPI:1861692824
Name:GAYLE WALLS-BROWN PLLC
Entity type:Organization
Organization Name:GAYLE WALLS-BROWN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:WALLS-BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, ACSW
Authorized Official - Phone:313-610-5711
Mailing Address - Street 1:19670 CHESTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1831
Mailing Address - Country:US
Mailing Address - Phone:313-610-5711
Mailing Address - Fax:
Practice Address - Street 1:20700 CIVIC CENTER DR
Practice Address - Street 2:170
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4140
Practice Address - Country:US
Practice Address - Phone:313-610-5711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801080183251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588772560OtherINDIVIDUAL NPI
MIOP36670Medicare PIN