Healthcare Provider Details

I. General information

NPI: 1376274605
Provider Name (Legal Business Name): KELLI BULL TZORIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6548 MINK DR
MIDLAND GA
31820-3732
US

IV. Provider business mailing address

6548 MINK DR
MIDLAND GA
31820-3732
US

V. Phone/Fax

Practice location:
  • Phone: 770-802-3483
  • Fax:
Mailing address:
  • Phone: 770-802-3483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number66825
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: