Provider Demographics
NPI:1063808616
Name:BULKLEY, CORRY J (LCPC)
Entity type:Individual
Prefix:
First Name:CORRY
Middle Name:J
Last Name:BULKLEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8258 VETERANS HWY
Mailing Address - Street 2:SUITE 13
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1457
Mailing Address - Country:US
Mailing Address - Phone:410-768-6088
Mailing Address - Fax:410-768-6444
Practice Address - Street 1:8258 VETERANS HWY
Practice Address - Street 2:SUITE 13
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1457
Practice Address - Country:US
Practice Address - Phone:410-768-6088
Practice Address - Fax:410-768-6444
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7114101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420562600Medicaid