Provider Demographics
NPI:1578031399
Name:LEWIS-BULTSMA, SHARON (PSYD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:LEWIS-BULTSMA
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 1:1012 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-3812
Mailing Address - Country:US
Mailing Address - Phone:714-931-2963
Mailing Address - Fax:
Practice Address - Street 1:1012 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3812
Practice Address - Country:US
Practice Address - Phone:714-931-2963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19732103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical