Basic Information
| Provider Information | |||||||||
| NPI: | 1003332289 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLERT | ||||||||
| FirstName: | MAREN | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 S 20TH AVE W | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558063526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187331331 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1025 MARSH ST | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560014752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076254031 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2017 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 23920 | MN | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 23920 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.