Provider Demographics
NPI:1457593741
Name:STULL, ANNE (MA)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:STULL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 KINGDOM WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6063
Mailing Address - Country:US
Mailing Address - Phone:919-865-5077
Mailing Address - Fax:919-882-8661
Practice Address - Street 1:5121 KINGDOM WAY STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6063
Practice Address - Country:US
Practice Address - Phone:919-865-5077
Practice Address - Fax:919-882-8661
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-08-4154103K00000X
NC3621103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1312677Medicaid