Provider Demographics
NPI:1154012524
Name:TULLOCH, KAREN
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:TULLOCH
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 1:3101 N FEDERAL HWY STE 606
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1018
Mailing Address - Country:US
Mailing Address - Phone:954-981-9301
Mailing Address - Fax:954-368-5915
Practice Address - Street 1:3101 N FEDERAL HWY STE 606
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1018
Practice Address - Country:US
Practice Address - Phone:954-981-9301
Practice Address - Fax:954-368-5915
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118193800Medicaid