Healthcare Provider Details

I. General information

NPI: 1992438931
Provider Name (Legal Business Name): TARA A BULKO MA, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5340 HOLIDAY TER
KALAMAZOO MI
49009-2196
US

IV. Provider business mailing address

6626 ROTHBURY ST
PORTAGE MI
49024-3145
US

V. Phone/Fax

Practice location:
  • Phone: 269-372-4140
  • Fax:
Mailing address:
  • Phone: 269-352-5684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401224519
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451022318
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: