Provider Demographics
NPI:1710448402
Name:STULL, KADA (MED/EDS)
Entity Type:Individual
Prefix:
First Name:KADA
Middle Name:
Last Name:STULL
Suffix:
Gender:F
Credentials:MED/EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5644 HARBORSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-3682
Mailing Address - Country:US
Mailing Address - Phone:570-484-1353
Mailing Address - Fax:
Practice Address - Street 1:3941 68TH AVE N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-6136
Practice Address - Country:US
Practice Address - Phone:570-484-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17981101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health