Provider Demographics
NPI:1336365139
Name:BULLIS, ANN BLYTH (LCSW)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:BLYTH
Last Name:BULLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 CLEAR DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-3687
Mailing Address - Country:US
Mailing Address - Phone:702-456-8312
Mailing Address - Fax:702-651-3503
Practice Address - Street 1:2801 S VALLEY VIEW BLVD
Practice Address - Street 2:#14
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-0116
Practice Address - Country:US
Practice Address - Phone:702-243-4357
Practice Address - Fax:702-228-0735
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4209-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical