Provider Demographics
NPI:1699310763
Name:CULLISON, KATE BODACK (PHD)
Entity type:Individual
Prefix:DR
First Name:KATE
Middle Name:BODACK
Last Name:CULLISON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 S DAWSON LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4681
Mailing Address - Country:US
Mailing Address - Phone:352-514-4210
Mailing Address - Fax:
Practice Address - Street 1:3100 E JOHN HINKLE PL STE 104
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-2611
Practice Address - Country:US
Practice Address - Phone:812-323-6001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TF0000X, 103TS0200X
IN20043309B103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool