Healthcare Provider Details

I. General information

NPI: 1194716365
Provider Name (Legal Business Name): BROOK LYN GULLICKSON ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 NE HOSTMARK ST SUITE 101
POULSBO WA
98370-6204
US

IV. Provider business mailing address

769 TUFTS AVE E
PORT ORCHARD WA
98366-4060
US

V. Phone/Fax

Practice location:
  • Phone: 360-697-7726
  • Fax:
Mailing address:
  • Phone: 360-871-0799
  • Fax: 360-871-0799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: