Healthcare Provider Details

I. General information

NPI: 1265680904
Provider Name (Legal Business Name): ANDREA GULLEY MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2008
Last Update Date: 09/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W JACKSON ST SUITE F
RIDGELAND MS
39157-2428
US

IV. Provider business mailing address

115 W JACKSON ST SUITE F
RIDGELAND MS
39157-2428
US

V. Phone/Fax

Practice location:
  • Phone: 601-853-9747
  • Fax: 601-898-4761
Mailing address:
  • Phone: 601-853-9747
  • Fax: 601-898-4761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT2206
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: