Healthcare Provider Details

I. General information

NPI: 1124120670
Provider Name (Legal Business Name): KATHRYN BULTMAN L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 E PARIS AVE SE
GRAND RAPIDS MI
49546-8371
US

IV. Provider business mailing address

2231 RIDGECROFT AVE SE
GRAND RAPIDS MI
49546-5759
US

V. Phone/Fax

Practice location:
  • Phone: 616-460-1857
  • Fax: 616-454-0061
Mailing address:
  • Phone: 616-460-1857
  • Fax: 616-454-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801082187
License Number StateMI

VIII. Authorized Official

Name: MS. KATHRYN BULTMAN
Title or Position: CLINICAL SOCIAL WORKER
Credential: LMSW
Phone: 616-460-1857