Provider Demographics
NPI:1831110568
Name:BULLICK, PATRICIA ANN
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:BULLICK
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:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-0478
Mailing Address - Country:US
Mailing Address - Phone:208-765-4795
Mailing Address - Fax:208-765-2903
Practice Address - Street 1:1686 W RIVERSTONE DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6051
Practice Address - Country:US
Practice Address - Phone:208-765-4795
Practice Address - Fax:208-765-2903
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 261661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807261800Medicaid
ID1693469Medicare PIN