Provider Demographics
NPI:1073329652
Name:BULGATZ, SIDNEY BENJAMIN
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:BENJAMIN
Last Name:BULGATZ
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 1:14139 AUTUMNWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-2242
Mailing Address - Country:US
Mailing Address - Phone:651-216-4783
Mailing Address - Fax:
Practice Address - Street 1:10450 185TH ST W STE 100
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6696
Practice Address - Country:US
Practice Address - Phone:612-509-1283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician