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General NPI Number Information
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NPI Number | 1083071872
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Entity Type | Individual
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Provider Name | MICHELLE TULLIS
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Gender | Female
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Dates
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Enumeration Date | 01/25/2016
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Last Update Date | 01/25/2016
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Provider Practice Location Address
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Address Line | 221 S METTER AVE
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City | COLUMBIA
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State | IL
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Zip | 62236-2253
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Country | US
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Telephone | 618-420-3353
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Fax |
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Provider Business Mailing Address
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Address Line | 854 MEADOWVIEW LN
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City | COLUMBIA
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State | IL
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Zip | 62236-1012
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Country | US
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Telephone | 618-420-3353
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 178.011541
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License Number State | IL
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