=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609221266
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY KAY BULMER LSW, LCDCIII
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2016
-----------------------------------------------------
Last Update Date | 05/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7774 GRAPHICS WAY
-----------------------------------------------------
City | LEWIS CENTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43035-8114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-301-8968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 NORTHWOODS BLVD STE A
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43235-7473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-301-8968
-----------------------------------------------------
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 | S0029111
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------