Healthcare Provider Details

I. General information

NPI: 1720922719
Provider Name (Legal Business Name): EMBERLIFE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2026
Last Update Date: 04/18/2026
Certification Date: 04/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3316 S 7TH ST
TERRE HAUTE IN
47802-4015
US

IV. Provider business mailing address

3316 S 7TH ST
TERRE HAUTE IN
47802-4015
US

V. Phone/Fax

Practice location:
  • Phone: 812-249-0171
  • Fax:
Mailing address:
  • Phone: 812-249-0171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARK ALLEN GULLEY
Title or Position: OWNER/CEO
Credential:
Phone: 812-249-0171