Healthcare Provider Details

I. General information

NPI: 1780176909
Provider Name (Legal Business Name): DAVID T KULLGREN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 ROHLWING RD
ELK GROVE VILLAGE IL
60007-3217
US

IV. Provider business mailing address

4157 W FLETCHER ST
CHICAGO IL
60641-5432
US

V. Phone/Fax

Practice location:
  • Phone: 847-524-8800
  • Fax:
Mailing address:
  • Phone: 312-622-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: