Provider Demographics
NPI:1730208729
Name:PULLIAM, JUDITH LYNN
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:LYNN
Last Name:PULLIAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9590 SW WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6924
Mailing Address - Country:US
Mailing Address - Phone:503-961-3562
Mailing Address - Fax:503-641-7621
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:SUITE 238
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-961-3562
Practice Address - Fax:503-961-3562
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical