Healthcare Provider Details

I. General information

NPI: 1760445977
Provider Name (Legal Business Name): DAVID PAYNE BULLIS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/12/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MGH 55 FRUIT STREET
BOSTON MA
02114
US

IV. Provider business mailing address

20 AUSTIN ST
MILTON MA
02186-1104
US

V. Phone/Fax

Practice location:
  • Phone: 617-219-1279
  • Fax:
Mailing address:
  • Phone: 617-698-1778
  • Fax: 781-843-9199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6826
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6826
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: