Provider Demographics
NPI:1962048090
Name:PULFORD, COREY
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:PULFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 BAYOU BLVD STE 8D
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1908
Mailing Address - Country:US
Mailing Address - Phone:850-474-9882
Mailing Address - Fax:
Practice Address - Street 1:4400 BAYOU BLVD STE 8D
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-1908
Practice Address - Country:US
Practice Address - Phone:850-474-9882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-86208106S00000X
FLIMH21513101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician