Provider Demographics
NPI:1790243780
Name:BULLMAN, DIANE KAYE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:KAYE
Last Name:BULLMAN
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 1:1627 W 75TH PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-3205
Mailing Address - Country:US
Mailing Address - Phone:317-252-4821
Mailing Address - Fax:
Practice Address - Street 1:402 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-3115
Practice Address - Country:US
Practice Address - Phone:317-408-9069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002503A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist