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General NPI Number Information
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NPI Number | 1871295055
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Entity Type | Individual
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Provider Name | DORNICHO SHANTA PULLIAM MSW
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Gender | Female
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Dates
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Enumeration Date | 03/20/2023
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Last Update Date | 03/20/2023
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Provider Practice Location Address
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Address Line | 6815 W CAPITOL DR STE 304
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City | MILWAUKEE
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State | WI
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Zip | 53216-2056
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Country | US
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Telephone | 414-909-1079
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Fax |
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Provider Business Mailing Address
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Address Line | 8443 N 101ST CT
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City | MILWAUKEE
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State | WI
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Zip | 53224-2430
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Country | US
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Telephone | 815-519-5256
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 130575-121
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License Number State | WI
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