Provider Demographics
NPI:1518393792
Name:BULTMAN, NATHAN (LPC, LLMFT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:BULTMAN
Suffix:
Gender:M
Credentials:LPC, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 GRAN VIA CT.
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9692
Mailing Address - Country:US
Mailing Address - Phone:616-240-3023
Mailing Address - Fax:
Practice Address - Street 1:6630 GRAN VIA CT NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9692
Practice Address - Country:US
Practice Address - Phone:616-240-3023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011996101YP2500X
MI4101006529106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist