Provider Demographics
NPI:1992168587
Name:HULLUM, HEATHER (BCBA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:HULLUM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 FORTUNE PKWY
Mailing Address - Street 2:SUITE 903
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6746
Mailing Address - Country:US
Mailing Address - Phone:904-538-0713
Mailing Address - Fax:904-538-0714
Practice Address - Street 1:3766 US HIGHWAY 17 STE 301
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-8876
Practice Address - Country:US
Practice Address - Phone:912-756-0656
Practice Address - Fax:904-538-0714
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-18-31775103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst