Provider Demographics
NPI:1295792257
Name:GULLI, LAITH F (MD,MSC,MSA,MSC)
Entity type:Individual
Prefix:
First Name:LAITH
Middle Name:F
Last Name:GULLI
Suffix:
Gender:M
Credentials:MD,MSC,MSA,MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 BRITISH AMERICAN BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1410
Mailing Address - Country:US
Mailing Address - Phone:518-389-6606
Mailing Address - Fax:
Practice Address - Street 1:350 ELK ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7351
Practice Address - Country:US
Practice Address - Phone:605-343-7262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011936103TC0700X
NY06000343106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical