Provider Demographics
NPI:1598563686
Name:BULTSMA, LEVI M
Entity type:Individual
Prefix:
First Name:LEVI
Middle Name:M
Last Name:BULTSMA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 BALEEN AVE
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-8888
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 UPLAND ST
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-8026
Practice Address - Country:US
Practice Address - Phone:907-335-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1754435Medicaid