Provider Demographics
NPI:1205252558
Name:BULMAN, CHARLES R (LADC, LPCC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:BULMAN
Suffix:
Gender:M
Credentials:LADC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 SIMPSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2440
Mailing Address - Country:US
Mailing Address - Phone:612-296-0348
Mailing Address - Fax:
Practice Address - Street 1:4505 WHITE BEAR PKWY STE 1500
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3697
Practice Address - Country:US
Practice Address - Phone:651-493-8150
Practice Address - Fax:651-493-9335
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303359101YA0400X
MNCC1392101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)