Provider Demographics
NPI:1558666578
Name:BULAVA, KIMBERLY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:BULAVA
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 1:820 KINSHIP RD
Mailing Address - Street 2:PO BOX 171
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785
Mailing Address - Country:US
Mailing Address - Phone:773-255-1055
Mailing Address - Fax:
Practice Address - Street 1:820 KINSHIP RD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-9998
Practice Address - Country:US
Practice Address - Phone:773-255-1055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-23
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9056103T00000X, 103TC0700X, 103TF0200X
IL071.008005103T00000X
IL071008005103TC0700X
FLPY 9056103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic