MEDICARE: TYISHA GULLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA.173438	OH

General Provider Information

NPI Number	:	1033998893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYISHA GULLY

Provider Business Mailing Address
First Line	:	1324 GRANVILLE ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43203-1641
Country	:	US
Telephone Number	:	614-537-1389
Fax Number	:

Provider Business Practice Location Address
First Line	:	1324 GRANVILLE ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43203-1641
Country	:	US
Telephone Number	:	614-537-1389
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2023
Last Update Date	:	09/21/2023

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Directions to “ TYISHA GULLY ” Practice Location

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