Provider Demographics
NPI:1447772173
Name:STULL, BOBBY MARTIN
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:MARTIN
Last Name:STULL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 WINDWARD DR
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-7948
Mailing Address - Country:US
Mailing Address - Phone:858-345-0379
Mailing Address - Fax:
Practice Address - Street 1:1616 CORNWALL AVE STE 100
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4642
Practice Address - Country:US
Practice Address - Phone:360-305-3275
Practice Address - Fax:360-734-5503
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPENDINGMedicaid