MEDICARE: GAYLE WALLS-BROWN PLLC

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	251S00000X	Community/Behavioral Health Agency	6801080183	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1588772560	OTHER	MI	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1861692824
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAYLE WALLS-BROWN PLLC

Provider Business Mailing Address
First Line	:	19670 CHESTERFIELD RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-1831
Country	:	US
Telephone Number	:	313-610-5711
Fax Number	:

Provider Business Practice Location Address
First Line	:	20700 CIVIC CENTER DR
Second Line	:	170
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-4140
Country	:	US
Telephone Number	:	313-610-5711
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL THERAPIST
Name	:	MRS. GAYLE ELAINE WALLS-BROWN
Credential	:	LMSW, ACSW
Telephone Number	:	313-610-5711

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	07/18/2007

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