Provider Demographics
NPI:1346722857
Name:PULLARA, ALEXIS DREW
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:DREW
Last Name:PULLARA
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 1:10514 RACETRACK RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-3241
Mailing Address - Country:US
Mailing Address - Phone:410-973-2301
Mailing Address - Fax:410-973-2305
Practice Address - Street 1:420 E NORTH POINTE DR APT 460
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-2354
Practice Address - Country:US
Practice Address - Phone:443-365-5077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD483106300Medicaid