Provider Demographics
NPI:1154560480
Name:GULLY, ERIC ALAN (PT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:ALAN
Last Name:GULLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 DELREY DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5091
Mailing Address - Country:US
Mailing Address - Phone:979-777-5669
Mailing Address - Fax:
Practice Address - Street 1:6 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1703
Practice Address - Country:US
Practice Address - Phone:808-244-5541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2010225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist