Healthcare Provider Details

I. General information

NPI: 1518628544
Provider Name (Legal Business Name): AMANDA GULLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 CHEROKEE ST NW STE 903
KENNESAW GA
30144-6782
US

IV. Provider business mailing address

PO BOX 748465
ATLANTA GA
30374-8465
US

V. Phone/Fax

Practice location:
  • Phone: 855-284-7483
  • Fax: 617-807-0958
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC016903
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: