Provider Demographics
NPI:1427138635
Name:GULLETTE, LYN (PHD)
Entity type:Individual
Prefix:
First Name:LYN
Middle Name:
Last Name:GULLETTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 W MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-9430
Mailing Address - Country:US
Mailing Address - Phone:303-926-7300
Mailing Address - Fax:303-604-4395
Practice Address - Street 1:400 S MCCASLIN BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9731
Practice Address - Country:US
Practice Address - Phone:303-926-7300
Practice Address - Fax:303-604-4395
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1210103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86576Medicare ID - Type Unspecified
CO86576Medicare UPIN