Provider Demographics
NPI:1114723590
Name:BULLEN, SAMUEL WALTER (RBT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WALTER
Last Name:BULLEN
Suffix:
Gender:
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 W BETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5408
Mailing Address - Country:US
Mailing Address - Phone:765-282-8222
Mailing Address - Fax:
Practice Address - Street 1:3601 W BETHEL AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5408
Practice Address - Country:US
Practice Address - Phone:765-282-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-24-386413106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician