Healthcare Provider Details

I. General information

NPI: 1811761711
Provider Name (Legal Business Name): MALLORY KAY BULCHAK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2023
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42669 GARFIELD RD
CLINTON TOWNSHIP MI
48038-1653
US

IV. Provider business mailing address

26545 AMERICAN DR
SOUTHFIELD MI
48034-6115
US

V. Phone/Fax

Practice location:
  • Phone: 800-395-3223
  • Fax:
Mailing address:
  • Phone: 800-395-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704352280
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704352280
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: