Healthcare Provider Details

I. General information

NPI: 1215150123
Provider Name (Legal Business Name): PAMELA ANITA GULLEY ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 NILLES RD STE 5
FAIRFIELD OH
45014-7205
US

IV. Provider business mailing address

1251 NILLES RD STE 5
FAIRFIELD OH
45014-7205
US

V. Phone/Fax

Practice location:
  • Phone: 513-939-0300
  • Fax: 513-939-0310
Mailing address:
  • Phone: 513-939-0300
  • Fax: 513-939-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3567
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3567
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number3567
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: