Basic Information
| Provider Information | |||||||||
| NPI: | 1467626192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GULLING-DEJOE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | CHRISTIN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LOCKWOOD DRIVE #210 | ||||||||
| Address2: | |||||||||
| City: | PITTSFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855860240 | ||||||||
| FaxNumber: | 5855860261 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 LOCKWOOD DRIVE #210 | ||||||||
| Address2: | |||||||||
| City: | PITTSFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855860240 | ||||||||
| FaxNumber: | 5855860261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2008 | ||||||||
| LastUpdateDate: | 01/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R073755 | NY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | R0737551 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.