Provider Demographics
NPI:1992438931
Name:BULKO, TARA A (MA, LPC, NCC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:A
Last Name:BULKO
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 ROTHBURY ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3145
Mailing Address - Country:US
Mailing Address - Phone:269-352-5684
Mailing Address - Fax:
Practice Address - Street 1:5340 HOLIDAY TER
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2196
Practice Address - Country:US
Practice Address - Phone:269-372-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401224519101Y00000X
MI6451022318101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6451022318OtherLARA
MI6401224519OtherLARA