Provider Demographics
NPI:1922196344
Name:KULHANEK, PHYLLIS MARY
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MARY
Last Name:KULHANEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 E BLUESTONE DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2952
Mailing Address - Country:US
Mailing Address - Phone:651-452-3200
Mailing Address - Fax:
Practice Address - Street 1:1803 E BLUESTONE DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2952
Practice Address - Country:US
Practice Address - Phone:651-452-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3731103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical