Provider Demographics
NPI:1619748977
Name:WTULICH, KIRSTEN MIA
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:MIA
Last Name:WTULICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 E FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-4728
Mailing Address - Country:US
Mailing Address - Phone:312-956-4724
Mailing Address - Fax:
Practice Address - Street 1:100 BULL ST STE 200
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-3378
Practice Address - Country:US
Practice Address - Phone:470-688-2532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-7655-447746106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician