=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851912265
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNALISA BULLER MA, NCC, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2020
-----------------------------------------------------
Last Update Date | 09/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 334 KAWAINUI ST
-----------------------------------------------------
City | KAILUA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96734-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-837-8423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1065 SNIDOW DR
-----------------------------------------------------
City | WEST LINN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97068-4349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-799-9771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | C7686
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------