Provider Demographics
NPI:1871295055
Name:PULLIAM, DORNICHO SHANTA (MSW)
Entity type:Individual
Prefix:
First Name:DORNICHO
Middle Name:SHANTA
Last Name:PULLIAM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8443 N 101ST CT
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-2430
Mailing Address - Country:US
Mailing Address - Phone:815-519-5256
Mailing Address - Fax:
Practice Address - Street 1:6815 W CAPITOL DR STE 304
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2056
Practice Address - Country:US
Practice Address - Phone:414-909-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130575-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker