Provider Demographics
NPI:1952318768
Name:BULLOUGH, JOHN DOUGLAS (MSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DOUGLAS
Last Name:BULLOUGH
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3133 44TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2313
Mailing Address - Country:US
Mailing Address - Phone:612-920-3626
Mailing Address - Fax:
Practice Address - Street 1:3133 44TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2313
Practice Address - Country:US
Practice Address - Phone:612-920-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN019971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800002071Medicare UPIN