Provider Demographics
NPI:1710434535
Name:TULLAR, BEVERLY ANN (LPC)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:TULLAR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:ANN
Other - Last Name:BALDWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:653 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1048
Mailing Address - Country:US
Mailing Address - Phone:903-746-7571
Mailing Address - Fax:
Practice Address - Street 1:653 LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1048
Practice Address - Country:US
Practice Address - Phone:903-746-7571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002516101YP2500X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional