Provider Demographics
NPI:1538234521
Name:BULLMER, CAROLE MARIE (EDD)
Entity type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:MARIE
Last Name:BULLMER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 WOODBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4091
Mailing Address - Country:US
Mailing Address - Phone:269-323-1011
Mailing Address - Fax:
Practice Address - Street 1:6100 NEWPORT RD STE 222
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9235
Practice Address - Country:US
Practice Address - Phone:269-324-1248
Practice Address - Fax:269-324-1248
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003175103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C94551Medicare ID - Type Unspecified
MIR77038Medicare UPIN