Provider Demographics
NPI:1174088843
Name:BULL, ELIZABETH (MS)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BULL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3132 HOLLYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5129
Mailing Address - Country:US
Mailing Address - Phone:480-444-8027
Mailing Address - Fax:
Practice Address - Street 1:308 CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2506
Practice Address - Country:US
Practice Address - Phone:404-308-8548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006548101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAPC006548OtherLICENSE NO.