Healthcare Provider Details

I. General information

NPI: 1467670950
Provider Name (Legal Business Name): TERI M BULLIS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TERI M BROOKS PH.D.

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 VINCENT PL
MC LEAN VA
22101-3615
US

IV. Provider business mailing address

75 MOUNT RD
CUMMINGTON MA
01026-9702
US

V. Phone/Fax

Practice location:
  • Phone: 802-380-1713
  • Fax:
Mailing address:
  • Phone: 802-380-1713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number796
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number796
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number796
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: