Provider Demographics
NPI:1841519402
Name:DULLE, MICHAEL DAVID (MA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:DULLE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 S 600 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1007
Mailing Address - Country:US
Mailing Address - Phone:801-428-3469
Mailing Address - Fax:801-359-3864
Practice Address - Street 1:68 S 600 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1007
Practice Address - Country:US
Practice Address - Phone:801-428-3469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5804086-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional