Provider Demographics
NPI:1477962355
Name:BULTMANN, MARY (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BULTMANN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410B SE 3RD STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEE'S SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063
Mailing Address - Country:US
Mailing Address - Phone:816-525-5333
Mailing Address - Fax:816-525-5334
Practice Address - Street 1:410B SE 3RD STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:LEE'S SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063
Practice Address - Country:US
Practice Address - Phone:816-525-5333
Practice Address - Fax:816-525-5334
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013017060101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional