Provider Demographics
NPI:1366865024
Name:BULTROWICZ, TARA (EDS, NCSP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:BULTROWICZ
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3723 FIRETHORN DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OH
Mailing Address - Zip Code:44202-5203
Mailing Address - Country:US
Mailing Address - Phone:330-926-3800
Mailing Address - Fax:
Practice Address - Street 1:431 STOW AVE
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-2521
Practice Address - Country:US
Practice Address - Phone:330-926-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1248561103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool