Provider Demographics
NPI:1467670950
Name:BULLIS, TERI M (PHD)
Entity Type:Individual
Prefix:DR
First Name:TERI
Middle Name:M
Last Name:BULLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:TERI
Other - Middle Name:M
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:75 MOUNT RD
Mailing Address - Street 2:
Mailing Address - City:CUMMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01026-9702
Mailing Address - Country:US
Mailing Address - Phone:802-380-1713
Mailing Address - Fax:
Practice Address - Street 1:1319 VINCENT PL
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3615
Practice Address - Country:US
Practice Address - Phone:802-380-1713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT796103TB0200X, 103TS0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool