Provider Demographics
NPI:1174539944
Name:GULLY, ROGER LEE (CERTIFIED REHAB THER)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:LEE
Last Name:GULLY
Suffix:
Gender:M
Credentials:CERTIFIED REHAB THER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-3007
Mailing Address - Country:US
Mailing Address - Phone:973-340-0890
Mailing Address - Fax:
Practice Address - Street 1:62 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-3007
Practice Address - Country:US
Practice Address - Phone:973-340-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26BT00004800225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner