MEDICARE: MRS. ALEXIS MICHAEL GULLY MSW, LCSW

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	1041C0700X	Clinical Social Worker	379250-3501	UT
2	1041C0700X	Clinical Social Worker	34005217A	IN

General Provider Information

NPI Number	:	1598880320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALEXIS MICHAEL GULLY MSW, LCSW

Provider Business Mailing Address
First Line	:	7334 HARBOUR ISLE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-3471
Country	:	US
Telephone Number	:	801-694-3836
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 BEACHWAY DR
Second Line	:	SUITE C
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-8506
Country	:	US
Telephone Number	:	317-788-4111
Fax Number	:

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	04/28/2008

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