Healthcare Provider Details

I. General information

NPI: 1558490078
Provider Name (Legal Business Name): GLORIA HULTQUIST CMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 8TH ST
CLARKSVILLE TN
37040-3093
US

IV. Provider business mailing address

3719 AISLE ST
CLARKSVILLE TN
37040-5571
US

V. Phone/Fax

Practice location:
  • Phone: 931-206-1086
  • Fax: 931-920-7332
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP0003245
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: