Healthcare Provider Details

I. General information

NPI: 1699310763
Provider Name (Legal Business Name): KATE BODACK CULLISON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E JOHN HINKLE PL STE 104
BLOOMINGTON IN
47408-2611
US

IV. Provider business mailing address

3209 S DAWSON LN
BLOOMINGTON IN
47403-4681
US

V. Phone/Fax

Practice location:
  • Phone: 812-323-6001
  • Fax:
Mailing address:
  • Phone: 352-514-4210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number20043309B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: