=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003378597
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMALLY TULOCH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2019
-----------------------------------------------------
Last Update Date | 04/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 256 WASHINGTON ST
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10553-1052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-613-0770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 S 7TH AVE APT 6B
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10550-3824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-343-0337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------