Provider Demographics
NPI:1124371752
Name:TULLOCH, ANITA M (LMFT)
Entity Type:Individual
Prefix:DR
First Name:ANITA
Middle Name:M
Last Name:TULLOCH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 TALLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-4332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:FL
Practice Address - Zip Code:32725
Practice Address - Country:US
Practice Address - Phone:386-668-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2722106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021850000Medicaid