Provider Demographics
NPI:1184085151
Name:DULL, BRONSON
Entity type:Individual
Prefix:
First Name:BRONSON
Middle Name:
Last Name:DULL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 SILVER FOX DR
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-3619
Mailing Address - Country:US
Mailing Address - Phone:360-635-3481
Mailing Address - Fax:
Practice Address - Street 1:825 E MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7171
Practice Address - Country:US
Practice Address - Phone:541-621-0303
Practice Address - Fax:458-226-2072
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500708648Medicaid