Provider Demographics
NPI:1396875787
Name:PULLIAM, THADA (LPC)
Entity type:Individual
Prefix:MRS
First Name:THADA
Middle Name:
Last Name:PULLIAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 NE BORDNER DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-6228
Mailing Address - Country:US
Mailing Address - Phone:816-554-1415
Mailing Address - Fax:
Practice Address - Street 1:1209 NW R IDGE DR.
Practice Address - Street 2:C
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015
Practice Address - Country:US
Practice Address - Phone:816-229-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999136662101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional