Provider Demographics
NPI:1487192977
Name:FURNESS ULLRICH, TINA (PSYD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FURNESS ULLRICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1712
Mailing Address - Country:US
Mailing Address - Phone:502-309-2408
Mailing Address - Fax:
Practice Address - Street 1:1190 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1712
Practice Address - Country:US
Practice Address - Phone:502-309-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171339103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical