Provider Demographics
NPI:1609680081
Name:BULALE, MARYAN ALI
Entity type:Individual
Prefix:
First Name:MARYAN
Middle Name:ALI
Last Name:BULALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2151
Mailing Address - Country:US
Mailing Address - Phone:612-298-2169
Mailing Address - Fax:
Practice Address - Street 1:3500 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2151
Practice Address - Country:US
Practice Address - Phone:612-298-2169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician