Provider Demographics
NPI:1982815858
Name:BULLARO, KELLY ANN (CSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:BULLARO
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:PECORA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CSW
Mailing Address - Street 1:2174 FEATHER GOLD CT
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5702
Mailing Address - Country:US
Mailing Address - Phone:801-816-1417
Mailing Address - Fax:
Practice Address - Street 1:2174 FEATHER GOLD CT
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5702
Practice Address - Country:US
Practice Address - Phone:801-816-1417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT64565223502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker