Provider Demographics
NPI:1760072318
Name:BULGER, BRANDON (RBT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BULGER
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5870 EL CAMINO REAL
Mailing Address - Street 2:STE 101
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008
Mailing Address - Country:US
Mailing Address - Phone:760-539-5818
Mailing Address - Fax:
Practice Address - Street 1:1343 BANYAN DRIVE
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028
Practice Address - Country:US
Practice Address - Phone:760-468-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB648492103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABACB648492Medicaid