Provider Demographics
NPI:1467506816
Name:KULLMAN, SUSAN BERTHA (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BERTHA
Last Name:KULLMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 S CORTEZ ST
Mailing Address - Street 2:STE 1C
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4354
Mailing Address - Country:US
Mailing Address - Phone:928-445-0231
Mailing Address - Fax:
Practice Address - Street 1:915 E GURLEY ST
Practice Address - Street 2:STE 105
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-3244
Practice Address - Country:US
Practice Address - Phone:928-445-0231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW2411101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ105659Medicare ID - Type Unspecified