Provider Demographics
NPI:1649729682
Name:TULLY, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 COLONIAL HOMES DR NW APT 806
Mailing Address - Street 2:806
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1272
Mailing Address - Country:US
Mailing Address - Phone:404-271-1846
Mailing Address - Fax:
Practice Address - Street 1:4720 PEACHTREE INDUSTRIAL BLVD STE 301
Practice Address - Street 2:
Practice Address - City:BERKELEY LAKE
Practice Address - State:GA
Practice Address - Zip Code:30071-5736
Practice Address - Country:US
Practice Address - Phone:770-674-4106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01-07-3700103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst